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From chen...@apache.org
Subject svn commit: r1517634 - in /ctakes/trunk/ctakes-examples/data: VascSurg_FollowUp_1.rtf VascSurg_PVD_1.rtf
Date Mon, 26 Aug 2013 18:38:25 GMT
Author: chenpei
Date: Mon Aug 26 18:38:25 2013
New Revision: 1517634

URL: http://svn.apache.org/r1517634
Log:
CTAKES-223 - Thanks John Green for contributing the sample clinical notes.  Added it to the
ctakes-examples project.  the dir structure may change once the gold annotations get started...

Added:
    ctakes/trunk/ctakes-examples/data/VascSurg_FollowUp_1.rtf
    ctakes/trunk/ctakes-examples/data/VascSurg_PVD_1.rtf

Added: ctakes/trunk/ctakes-examples/data/VascSurg_FollowUp_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/VascSurg_FollowUp_1.rtf?rev=1517634&view=auto
==============================================================================
--- ctakes/trunk/ctakes-examples/data/VascSurg_FollowUp_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/VascSurg_FollowUp_1.rtf Mon Aug 26 18:38:25 2013
@@ -0,0 +1,28 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Vascular Surgery. 
+Note detail level (1-5): 2.
+Level of abbreviation (Low/Medium/High): High.
+
+CC/HPI:
+Mr X is a 77 yo white male w/ a PMH sig. for 3 strokes, 20 year history of diabetes, chronic
COPD, PShx sig. for a bilat. aortofem bypass in 2005, and TAA repair at UCSF in Feb 2011.
CT angio was n/s for expansion, however I am concerned about his LEs.
+
+ROS:
+Unremarkable with the exception of his vasc/LE exam and known SOB associated with COPD. 
+
+PE:
+Mr X is a well appearing 78 yo male A&Ox3.
+Vit: BP L 140/68, R 159/77, AFVSS.
+Card: No r/m/g, rrr.
+Neuro: Hx of three strokes->neuro deficits wo change.
+Pulm: SOB associated with his long standing emphysema. No w/r/r. Ctab.
+Abd: Nbs, non tender, non distended.
+LE/Vasc: Dependent rubor consistent with long standing dbx. No edema. No claudication. BP
significantly lower on L than R. R radial pulse barely palpable, Pop a. not palpable bilat,
dp/pt not palpable and not appreciated by doppler. Cap refill >5sec. Feet cold to touch.
No claudication, however. Sensation intact bilat.
+
+Lab/Anc:
+CTA of repaired TAA NS for expansion.
+
+A/P:
+Mr X is 5 months s/p TAA repair at UCSF. CTA of endograft not significant for expansion.
+- Follow up in 3 months.
+- CTA prior to followup.
\ No newline at end of file

Added: ctakes/trunk/ctakes-examples/data/VascSurg_PVD_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/VascSurg_PVD_1.rtf?rev=1517634&view=auto
==============================================================================
--- ctakes/trunk/ctakes-examples/data/VascSurg_PVD_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/VascSurg_PVD_1.rtf Mon Aug 26 18:38:25 2013
@@ -0,0 +1,38 @@
+Case description for C-Takes documenting:
+Setting: Inpatient.
+Specialty: Vascular Surgery. 
+Note detail level (1-5): 3.
+Level of abbreviation (Low/Medium/High): Medium.
+
+Mr. X is a 57 y/o M with a multiple year history of worsening RLE numbness, tingling, and
burning pain. He reports this started several years ago and has progressed over the past year
to include his foot. His ability to walk has worsened and he cannot even walk half of a block
due to pain. He also reports several years of spontaneous ulcers on his shins and now a new
ulcer to his right 2nd toe over the past 3 weeks. Patient denies any trauma or skin opening
to that area. Patient was seen by a podiatrist who started him on Augmentin and a topical
antifungal over 1 week ago.
+
+ROS:
+Patient denies any other symptoms to include fevers, chills shortness of breath, chest pain,
nausea, vomiting, abdominal pain, constipation, diarrhea, melena, rashes, peripheral edema.
+
+PMH: HTN, peripheral neuropathy, alcohol use, Crohn's disease, diverticulosis, OA.
+
+PSH: Multiple pilonidal I&Ds.
+
+Meds: Toprol XL 200mg daily, nifedipine 30mg daily, gabapentin 600mg TID, celebrex 100mg
daily, desonide topical 0.05% ointment PRN, vit b12 1g daily, mupirocin 2% to
+wounds BID, vancomycin 125mg QID, azathioprine 150mg daily, humira qweek, ammonium lactate
daily, flagyl 250mg QUD.
+
+All: lisinopril.
+
+FH: HTN, DM
+
+SH: Smokes 3 cigars a day x 30 years, drinks multiple shots of alcohol daily, denies illicit
drug use. No h/o alcohol withdrawl per patient.
+
+PE:
+Vitals: BP 151/101, HR 75, T 98.3, 98% RA
+Gen: Patient A&Ox4, thin-appearing, appears older than stated age.
+CV: RRR, no r/m/g.
+Resp: CTAB, no wheezing, rhonchi, rales.
+Neuro: RLE with light sensation intact throughout, motor appears intact but pt effort limited
due to pain.
+Ext: RLE - Multiple healing and well-healed ulcerations on shin, small, clean superficial
ulcer present on dorsum of 2nd right digit over middle phalanx approx 1.5 cm x 0.5 cm. No
signs of infection, no purulence.  LLE with similar ulcers to anterior shin, no obvious foot
ulcers.
+Vasc: RLE Ð TP palpable (ABI 0.6), DP dopplerable (ABI 0.6). LLE Ð TP and DP palp (ABI
>1)
+Labs: WBC 8.3 (15.4 on admission), H/H 11.3/35, lytes unremarkable, Hgb A1C 5.9.
+
+A/P:
+PVD - 57 M with progressively worsening RLE and foot pain and concern for arterial insufficiency.
+-Etiology of foot/shin ulcers and pain is unclear at this time, but vascular disease is high
on my index of suspicion. Recommend keeping wound clean and finishing course of antibiotics
as already started. We will bring the patient to the vascular surgery clinic in the morning
and perform formal ABIs with toe pressures. Pending those results, he may require angiography
and intervention tomorrow.
+-We will continue to follow along. Please contact us with questions or concerns.
\ No newline at end of file



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