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From chen...@apache.org
Subject svn commit: r1519693 - in /ctakes/trunk/ctakes-examples/data: OBGYN_Gen_Abscess_1.rtf VascSurg_AAA_Leak_1.rtf VascSurg_RO-AAA_1.rtf VascSurg_RO-DVT_1.rtf
Date Tue, 03 Sep 2013 14:17:44 GMT
Author: chenpei
Date: Tue Sep  3 14:17:43 2013
New Revision: 1519693

URL: http://svn.apache.org/r1519693
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/OBGYN_Gen_Abscess_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/OBGYN_Gen_Abscess_1.rtf?rev=1519693&view=auto
--- ctakes/trunk/ctakes-examples/data/OBGYN_Gen_Abscess_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/OBGYN_Gen_Abscess_1.rtf Tue Sep  3 14:17:43 2013
@@ -0,0 +1,30 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Ob/Gyn. 
+Note detail level (1-5): 4.
+Level of abbreviation (Low/Medium/High): Medium.
+Mrs. X is a 45 y/o G2P2 with LMP of 6Feb10 using BTL for contraception. She presents to the
clinic for f/u of labial and perianal abscess for which she was seen last week. Patient was
recently traveling in Brazil. Patient arrived in a hotel in Rio on 10Jan which she described
as Òincredibly filthyÓ. Within 2 weeks of arriving she developed an acute throat irritation
("Laryngitis" in her words) that persisted apprx 2 weeks during which time she felt feverish
and short of breath with severe general malaise. Appx one month after arriving she noticed
a cyst on her labia majora as well as around her anus and enlargement of the inguinal lymph
nodes. When asked to hypothesize on what may have caused the infection, she feels it may have
been the toilet seat in the hotel room. Cysts came and went as she popped them, some as large
as "marbles" and one the size of a "golf ball". Patient saw provider in Rio who performed
I&D of labial and perianal abscesses. The primary abscess was drained wi
 th approx 4cc of fluid being removed and she returned home to Austin. Today she states that
she continues to feel some swelling in the area but it has overall improved. She continues
to feel malaise and "not herself". She is currently in 3/10 pain and states that, currently,
most of lesions are healed after a course of "something" that they gave her in Rio. Also of
note and concern to the patient is a new onset rash in the right axilla as well as medial
thigh. She denies any significant medical history or any similar occurences in the past. She
reports that she is in a monogamous relationship but is amenable to STI testing. Denies sick
contacts. Denies CP, SOB, VB/Discharge, fever/nv.
+ROS: General malaise, otherwise unremarkable.
+PMHx: Noncontrib.
+PSHx: Breast augmentation, BTL.
+Meds: Bactrim for abscess (obtained in Rio, read from pill bottle).
+Allergies: NKDA.
+OB: TSVD x 2, uncomplicated.
+Gyn: Denies STIs and abnormal paps, BTL.
+FamHx: Noncontrib.
+Vit: BP 124/71 HR 70 RR 18 Tc 98.0
+PE: Reveals a thin, well developed caucasian woman of stated age in no acute distress. 
+Pelvic: Speculum exam: Two lesions on the patients right labia majora and one on the left.
All three healing well at this time. No other lesions noted on the exterior. No lesions on
the interior. Posterior cervix, medium sized, parous, not friable, no discharge. Palpable
inguinal lymph nodes bilaterally approximately the size of large marbles, very prominent.

+CV: No m/r/g, rrr.
+Pulm: CTAB.
+Abd: Non-distended, symettrical, flat, well toned. Not tender to palpation. Normal bowel
sounds auscultated. 
+Skin: Silver dollar size erythematous lesions at approx the location of the right axilla
as wel as the right medial thigh.
+Swabbed KOH/Wet prep, Gon/Chlam pending.
+Genital skin abscess: reveals a 45 y/o G2P2 with LMP appx 2 weeks ago using BTL for contraception
with labial and perianal abscess. Abscess appears to be healing well w/o e/o further infection.
Pt had concurrent inguinal lymphadenectomy, fever, chills, malaise and laryngitis and was
traveling at the time. Considering these findings, will test for HIV, RPR and gc/chlamydia.
Pt amenable to being tested for STIs. 1g azithromycin given prophylactic for LGV- if positive
will continue with 2 additional weekly doses. Will refer to derm for eval of axillary/thigh
skin lesions. Pt is to f/u in one week to review lab results. Return precautions discussed.
Pt voiced understanding of plan, all questions answered.

Added: ctakes/trunk/ctakes-examples/data/VascSurg_AAA_Leak_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/VascSurg_AAA_Leak_1.rtf?rev=1519693&view=auto
--- ctakes/trunk/ctakes-examples/data/VascSurg_AAA_Leak_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/VascSurg_AAA_Leak_1.rtf Tue Sep  3 14:17:43 2013
@@ -0,0 +1,26 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Vascular Surgery. 
+Note detail level (1-5): 3.
+Level of abbreviation (Low/Medium/High): Low.
+Mr X is a 78 yo white male w/ a PMH significant for diabetes and AAA. PShx significant for
an EVAR repair in 2010 of the AAA. He presents to the clinic today for follow up of the EVAR
repair by CTA. A mild sack expansion was noted one year ago by CTA as part of follow up to
the initial fix. Additionally, Mr X lives alone and recently lost his wife of 32 years. He
has complained of some mild buttock pain upon ambulation.
+Patient denies any fever, night sweats, n/v. No SOB, chest pain or extremeity pain.
+Physical exam reveals a well groomed man who appears his stated age.
+CV: No m/r/g.
+Pulm: CTAB.
+Ext/Vasc: No carotid bruits. No LE edema. Brachial/Radial pulses intact. Dp/Pt: Dp palpable
bilaterally, Pt by doppler, biphasic bilaterally. Good cap refill bilat.
+CTA: Endoleak (Type Ib?) w/ slight inc in diam of AAA w/ possbile retrograde flow from right
common iliac.
+US Duplx:
+1/13: A-P 5.5, Cor 5.77.
+7/12: A-P 5.2, Cor 5.31.
+Mr X is a 78 yo white male, doing well generally, but for the slow expansion of the excluded
aneurysmal sack by possible type Ib endleak. Schedule for arteriogram for potential placement
of extension of the right limb of the existing graft.

Added: ctakes/trunk/ctakes-examples/data/VascSurg_RO-AAA_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/VascSurg_RO-AAA_1.rtf?rev=1519693&view=auto
--- ctakes/trunk/ctakes-examples/data/VascSurg_RO-AAA_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/VascSurg_RO-AAA_1.rtf Tue Sep  3 14:17:43 2013
@@ -0,0 +1,20 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Vascular Surgery. 
+Note detail level (1-5): 1.
+Level of abbreviation (Low/Medium/High): Low.
+Mr. X is a 68 yo white male with a PMH significant for MI 6 years ago that was treated with
stenting who presents to the clinic today for f/u of aortic duplex scan requested after seeing
him to r/o carotid disease on referal from opthamology due to rapidly expanding cataract.
Carotid disease was ruled out at last appointment. AAA screening was requested based on age/race/smoking
+No fevers/chills/night sweats. Pt denies SOB, n/v, Chest pain. No pain on ambulation.
+No bruits audible at the carotids. Brachial/Radial intact bilaterally. DP's palpable bilat,
however PT's were not. On duplex they were found to be loud and audible but biphasic bilat.
+US Duplex was NS for AAA.
+Mr X is a 68 year old man who was screened for AAA. He was not found to have a AAA. It is
our recommendation that he not need to be seen again for AAA.

Added: ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT_1.rtf?rev=1519693&view=auto
--- ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT_1.rtf Tue Sep  3 14:17:43 2013
@@ -0,0 +1,18 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Vascular Surgery. 
+Note detail level (1-5): 1.
+Level of abbreviation (Low/Medium/High): High.
+HPI/CC: Mrs. X is a 60 yo white female with a PMH significant for HTN, CAD, AFIB, DMtype2
who presents to the clinic today for f/u to r/o a DVT after RLE edema was appreciated on PE
at a f/u apt s/p high saphenous vein ligation and stab phlebectomy of the ipsilateral leg
around Feb of 2010. Patient expresses concern over sutures remaining at the incision sites
as well as a lesion on her L arm that was noted after IV access was attempted by a tech post-op.
+ROS: Pt denies cp/sob. Unremarkable otherwise. 
+PE: Mrs X is a well appearing woman who appears her stated age. BP-R: 118/76, BP-L: 134/78.
Radial pulses 2+ bilaterally. Could not palpate pedal pulses or pop. pulses bilat., however,
pedal pulses 2 by doppler.
+ANC: Right LE duplex indicates no DVT.
+A/P: Mrs X is a 60 yo female presenting to clinic for f/u to r/o a DVT s/p a high ligation
of saphenous vein and stab phlebectomy of right leg. Some sutures remained and were removed.
Patient was counceled on hot compress therapy for superficial phlebitis and advised that it
should resolve with time. Given the exclusion of DVT, no further appointments are necessary.

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