TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
CHIEF COMPLAINT:  I need refills. HISTORY OF PRESENT ILLNESS:   The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try. OBJECTIVE: Well developed and well nourished. She does not appear to be in any acute distress. Cardiovascular: Regular rhythm. No murmurs, gallops, or rubs. Capillary refill less than 3 seconds. Peripheral pulses are 2+ bilaterally. Respiratory: Her lungs are clear to auscultation bilaterally with good effort. No tenderness to palpation over chest wall. Musculoskeletal: She has full range of motion of all four extremities. No tenderness to palpation over long bones. Skin: Warm and dry. No rashes or lesions. Neuro: Alert and oriented x3. Cranial nerves II-XII are grossly intact. No focal deficits. PLAN:  I did refill her medications. I have requested that she have her primary doctor forward her records to me. I have discussed Chantix and its use and success rate. She was given a prescription, as well as a coupon. She is to watch for any worsening signs or symptoms. She verbalized understanding of discharge instructions and prescriptions. I would like to see her back to proceed with her preventive health measures.
CHIEF COMPLAINT:   Headache. HPI:  This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs. PMH:  As above. MEDS:   Vicodin. ALLERGIES:   None. PHYSICAL EXAM: BP 180/110 Pulse 65 RR 18 Temp 97.5. Mr. P is awake and alert, in no apparent distress. HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,Neck: Supple, no meningismus. Lungs: Clear. Heart: Regular rate and rhythm, no murmur, gallop, or rub. ,Abdomen: Benign. Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. ,COURSE IN THE ED: Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. ,IMPRESSION:  Headache, improved. Intracranial aneurysm. PLAN:  The patient will return tomorrow am for his angiogram.
CHIEF COMPLAINT:   Right hydronephrosis. HISTORY OF PRESENT ILLNESS:  The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. Again, she is scheduled for mastectomy in two weeks. She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. There was no dilation of the right ureter noted. Urinalysis today is microscopically negative. PAST MEDICAL HISTORY:  Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension. PAST SURGICAL HISTORY:  Lumpectomy, hysterectomy. MEDICATIONS:   Diovan HCT 80/12.5 mg daily, metformin 500 mg daily. ALLERGIES:   None. FAMILY HISTORY:  Noncontributory. SOCIAL HISTORY:   She is retired. Does not smoke or drink. REVIEW OF SYSTEMS:   I have reviewed his review of systems sheet and it is on the chart. PHYSICAL EXAMINATION:   Please see the physical exam sheet I completed. Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness. IMPRESSION AND PLAN:  Marked right hydronephrosis without hydruria. She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005. I will try to obtain the report to see if the right kidney was evaluated at that time. She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney. She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. She will call us back to schedule the x-rays. She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. There is also a question of a stone present in the kidney. She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.
CHIEF COMPLAINT:  Burn, right arm. HISTORY OF PRESENT ILLNESS:  This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care. PAST MEDICAL HISTORY: Noncontributory. MEDICATIONS: None. ALLERGIES: None. PHYSICAL EXAMINATION:  GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine. FINAL DIAGNOSIS: 1. First-degree and second-degree burns, right arm secondary to hot oil spill. 2. Workers' Compensation industrial injury. TREATMENT:  The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed. DISPOSITION:  Home.
CHIEF COMPLAINT:  Marginal zone lymphoma. HISTORY OF PRESENT ILLNESS:  This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma). Overall, she is doing well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. She has normal bowel and bladder habits. No melena or hematochezia. CURRENT MEDICATIONS: Macrobid 100 mg q.d. ALLERGIES: Sulfa, causes nausea and vomiting. REVIEW OF SYSTEMS:  As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. She is status post a left partial nephrectomy as a new born. 2. In 2008 she had a right ankle fracture. SOCIAL HISTORY:  She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter. FAMILY HISTORY: Her mother had uterine cancer. Her father had liver cancer. PHYSICAL EXAM: VIT:
CHIEF COMPLAINT:  Iron deficiency anemia. HISTORY OF PRESENT ILLNESS:  This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis. On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells. Her iron levels were 5 and her percent transferrin was 2. There was no evidence of hemolysis. Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth. She currently has an IUD, so she is not menstruating. She was discharged from the hospital on iron supplements. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. She specifically denies melena or hematochezia. CURRENT MEDICATIONS:  Iron supplements and Levaquin. ALLERGIES:  Penicillin. REVIEW OF SYSTEMS:   As per the HPI, otherwise negative. PAST MEDICAL HISTORY: She is status post birth of a baby girl 5 months ago. She is G1, P1. She is currently using an IUD for contraception. SOCIAL HISTORY:  She has no tobacco use. She has rare alcohol use. No illicit drug use. FAMILY HISTORY:  Her maternal grandmother had stomach cancer. There is no history of hematologic malignancies. PHYSICAL EXAM: GEN:
DIAGNOSES: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis. CHIEF COMPLAINT:  Unobtainable as the patient is intubated for respiratory failure. CURRENT HISTORY OF PRESENT ILLNESS:  This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy. PAST MEDICAL HISTORY: Otherwise nondescript as is the past surgical history. SOCIAL HISTORY: There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister. FAMILY HISTORY: Otherwise noncontributory. REVIEW OF SYSTEMS:  Not otherwise pertinent. PHYSICAL EXAMINATION: GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated. VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16. HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place. NECK: No jugular venous pressure distention. CHEST: Coarse breath sounds bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line. EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet. LABORATORY STUDIES: The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13. IMPRESSION/PLAN: At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.
CHIEF COMPLAINT:  "Trouble breathing.",HISTORY OF PRESENT ILLNESS:  A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly. PAST MEDICAL HISTORY:   Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage. PAST SURGICAL HISTORY:   IVC filter placement 1999.
CHIEF COMPLAINT:  "I have had trouble breathing for the past 3 days",HISTORY:  69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing. Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since. PMH:  DM, HTN, COPD, CAD,PSH: CABG, appendectomy, tonsillectomy,FH:   Non-contributory,SOCH:  Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren. He smokes 1 pack a day of Newport for 30 years and is a social drinker. He denies any illicit drug use. TRAVEL HISTORY:  Denies any recent travel overseas,ALLERGIES:  Denies any drug allergies,HOME MEDICATIONS:   Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:   Same as above,PHYSICAL EXAM: Vital signs are: Temp. 99.3 F / BP 138/92, Resp. 22, P 88,General: Patient is in mild acute respiratory distress,HEENT: Head: Atraumatic, normocephalic,Eyes:
CHIEF COMPLAINT:  Pressure decubitus, right hip. HISTORY OF PRESENT ILLNESS:  This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms. PAST MEDICAL HISTORY:  Back closure for spina bifida, hysterectomy, breast reduction, and a shunt. SOCIAL HISTORY:  She denies the use of alcohol, illicits, or tobacco. MEDICATIONS:  Pravachol, Dilantin, Toprol, and Macrobid. ALLERGIES:  SULFA AND LATEX. REVIEW OF SYSTEMS:  Other than the above aforementioned, the remaining ROS is unremarkable. PHYSICAL EXAMINATION: GENERAL: A pleasant female with deformity of back. HEENT: Head is normocephalic. Oral mucosa and dentition appear to be normal. CHEST: Breath sounds equal and present bilateral. CVS: Sinus. GI: Obese, nontender, no hepatosplenomegaly. EXTREMITIES: Deformity of lower extremities secondary to spina bifida. SKIN: She has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue. PLAN:  Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week. DIAGNOSIS:  Sequelae of spina bifida; pressure decubitus of right hip area.
CHIEF COMPLAINT:   Itchy rash. HISTORY OF PRESENT ILLNESS:  This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day. PAST MEDICAL HISTORY:  Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy. REVIEW OF SYSTEMS:  As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms. SOCIAL HISTORY:  The patient is accompanied with his wife. FAMILY HISTORY:  Negative. MEDICATIONS:  None. ALLERGIES:  TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN. PHYSICAL EXAMINATION:  VITAL SIGNS: The patient was afebrile. He is slightly tachycardic, 105, but stable blood pressure and respiratory rate. GENERAL: The patient is in no distress. Sitting quietly on the gurney. HEENT: Unremarkable. His oral mucosa is moist and well hydrated. Lips and tongue look normal. Posterior pharynx is clear. NECK: Supple. His trachea is midline. There is no stridor. LUNGS: Very clear with good breath sounds in all fields. There is no wheezing. Good air movement in all lung fields. CARDIAC: Without murmur. Slight tachycardia. ABDOMEN: Soft, nontender. SKIN: Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms. He noted some on his buttocks as well. Remaining of the exam is unremarkable. ED COURSE:  The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable. IMPRESSION:   ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS. ASSESSMENT AND PLAN:  The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess. He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off. In the meantime, I think he can be managed with some antihistamine over-the-counter. He is responding already to Benadryl and the epinephrine that we gave him here. He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation. He is discharged in stable condition.
CHIEF COMPLAINT:  Headache. HISTORY OF PRESENT ILLNESS:   This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma. Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative. PMH:  Acne. Psychiatric history is unremarkable. PSH:  Right knee surgery. SH:  The patient is single. Living at home. No smoking or alcohol. FH:  Noncontributory. ALLERGIES: No drug allergies. MEDICATIONS:  Accutane and Ovcon. PHYSICAL EXAMINATION: VITALS: Temperature of 97.8 degrees F.  pulse of 80, respiratory rate of 16, and blood pressure is 131/96. GENERAL: This is a 16-year-old white female. She is awake, alert, and oriented x3. She does appear bit uncomfortable. HEAD: Normocephalic and atraumatic. EYES: The pupils were equal and reactive to light. Extraocular movements are intact. ENT: TMs are clear. Nose and throat are unremarkable. NECK: There is no evidence of nuchal rigidity. She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles. Palpation clearly causes having exacerbation of her discomfort. CHEST: Thorax is unremarkable. GI: Abdomen is nontender. MUSCLES: Extremities are unremarkable. NEURO: Cranial nerves II through XII are grossly intact. Motor and sensory are grossly intact. ,SKIN: Skin is warm and dry. ED COURSE:   The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort. DIAGNOSES: 1. Muscle tension cephalgia. 2. Right trapezius and rhomboid muscle spasm. PLAN:  Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20. She was instructed to apply warm compresses and perform gentle massage. Follow up with regular provider as needed. Return if any problems.