TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
CHIEF COMPLAINT:   Well-child check. HISTORY OF PRESENT ILLNESS:   This is a 12-month-old female here with her mother for a well-child check. Mother states she has been doing well. She is concerned about drainage from her left eye. Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning. She states it is worse when the child gets a cold. She has been using massaging when she can remember to do so. The patient is drinking whole milk without problems. She is using solid foods three times a day. She sleeps well without problems. Her bowel movements are regular without problems. She does not attend daycare. DEVELOPMENTAL ASSESSMENT:   Social: She can feed herself with fingers. She is comforted by parent’s touch. She is able to separate and explore. Fine motor: She scribbles. She has a pincer grasp. She can drink from a cup. Language: She says dada. She says one to two other words and she indicates her wants. Gross motor: She can stand alone. She cruises. She walks alone. She stoops and recovers. PHYSICAL EXAMINATION: General: She is alert, in no distress. Vital signs: Weight: 25th percentile. Height: 25th percentile. Head circumference: 50th percentile. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Left eye with watery secretions and crusted lashes. Conjunctiva is clear. TMs are clear bilaterally. Nares are patent. Mild nasal congestion present. Oropharynx is clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular. No murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. GU: Female external genitalia. Extremities: Symmetrical. Femoral pulses are 2+ bilaterally. Full range of motion of all extremities. Neurologic: Grossly intact. Skin: Normal turgor. Testing: Hearing and vision assessments grossly normal. ASSESSMENT: 1. Well child. 2. Left lacrimal duct stenosis. PLAN:   MMR #1 and Varivax #1 today. VIS statements given to Mother after discussion. Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct. Anticipatory guidance for age. She is to return to the office in three months.
CHIEF COMPLAINT:   Well-child check and school physical. HISTORY OF PRESENT ILLNESS:   This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors. DEVELOPMENTAL ASSESSMENT:   Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle. REVIEW OF SYSTEMS:   He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising. MEDICATIONS:   No daily medications. ALLERGIES:   Cefzil. IMMUNIZATIONS:   His immunizations are up to date. PHYSICAL EXAMINATION: General: He is alert and in no distress, afebrile. HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular. No murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. GU: Tanner III. Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities. Back: No scoliosis. Neurological: Grossly intact. Skin: Normal turgor. No rashes. Hearing: Grossly normal. ASSESSMENT:   Well child. PLAN:   Anticipatory guidance for age. He is to return to the office in one year.
CHIEF COMPLAINT:   Well-child check sports physical. HISTORY OF PRESENT ILLNESS:   This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed. His last exacerbation was 04/04. He has been very competitive in his sports this spring and summer and has had no issues since that time. He eats well from all food groups. He has very good calcium intake. He will be attending Maize High School in the ninth grade. He has same-sex and opposite-sex friends. He has had a girlfriend in the past. He denies any sexual activity. No use of alcohol, cigarettes or other drugs. His bowel movements are without problems. His immunizations are up to date. His last tetanus booster was in 07/03. CURRENT MEDICATIONS:   As above. ALLERGIES:  He has no known medication allergies. REVIEW OF SYSTEMS: Constitutional: He has had no fever. HEENT: No vision problems. No eye redness, itching or drainage. No earache. No sore throat or congestion. Cardiovascular: No chest pain. Respiratory: No cough, shortness of breath or wheezing. GI: No stomachache, vomiting or diarrhea. GU: No dysuria, urgency or frequency. Hematological: No excessive bruising or bleeding. He did have a minor concussion in 06/04 while playing baseball. PHYSICAL EXAMINATION: General: He is alert and in no distress. Vital signs: He is afebrile. His weight is at the 75th percentile. His height is about the 80th percentile. HEENT: Normocephalic. Atraumatic. Pupils are equal, round and reactive to light. TMs are clear bilaterally. Nares patent. Nasal mucosa is mildly edematous and pink. No secretions. Oropharynx is clear. Neck: Supple. Lungs: Good air exchange bilaterally. Heart: Regular. No murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. GU: Male. Testes descended bilaterally. Tanner IV. No hernia appreciated. Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities. Back: No scoliosis. Neurological: Grossly intact. Skin: Normal turgor. Minor sunburn on upper back. Neurological: Grossly intact. ASSESSMENT: 1. Well child. 2. Asthma with good control. 3. Allergic rhinitis, stable. PLAN:   Hearing and vision assessment today are both within normal limits. Will check an H&H today. Continue all medications as directed. Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue. Anticipatory guidance for age. He is to return to the office in one year or sooner if needed.
CHIEF COMPLAINT:  Irritable baby with fever for approximately 24 hours. HISTORY OF PRESENT ILLNESS:  This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol. PAST MEDICAL HISTORY:  This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness. PAST SURGICAL HISTORY:  He has had no previous surgeries. MEDICATION (S):  He takes no medications on a regular basis. REVIEW OF SYSTEMS:  Positive for those things mentioned already in the past medical history and history of present illness. FAMILY HISTORY:  The family history is noncontributory. SOCIAL HISTORY:  This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker. PHYSICAL EXAMINATION: VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees. HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest. HEART: The heart rate is rapid, but there was no murmur noted. LUNGS: The lungs are clear. ABDOMEN: The abdomen is without mass, distention, or visceromegaly. GENITOURINARY/RECTAL: Examination within normal limits. EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign. NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability. SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation. CLINICAL IMPRESSION (S):  Likely viral syndrome, viral meningitis, flu syndrome. PLAN:  Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.
CHIEF COMPLAINT:  Congestion and cough. HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion. ALLERGIES:  She has no known drug allergies. MEDICATIONS: None except the Amoxil and Aldex started on Monday. PAST MEDICAL HISTORY: Negative. SOCIAL HISTORY:  She lives with mom, sister, and her grandparent. BIRTH HISTORY:  She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth. IMMUNIZATIONS:  Also up-to-date. PAST SURGICAL HISTORY:  Negative. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Her respiratory rate was approximately 60 to 65. GENERAL: She was very congested and she looked miserable. She had no retractions at this time. HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact. NECK: Supple. Full range of motion. CARDIOVASCULAR EXAM: She was tachycardic without murmur. LUNGS: Revealed diffuse expiratory wheezing. ABDOMEN: Soft, nontender, and nondistended. EXTREMITIES: Showed no clubbing, cyanosis or edema. LABORATORY DATA: Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending. IMPRESSION AND PLAN: RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.
CHIEF COMPLAINT:   Chronic otitis media. HISTORY OF PRESENT ILLNESS:   This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia. ALLERGIES:   None. MEDICATIONS:   None. FAMILY HISTORY:   Noncontributory. MEDICAL HISTORY:  Mild reflux. PREVIOUS SURGERIES:   None. SOCIAL HISTORY:  The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure. PHYSICAL EXAMINATION:  Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds. IMPRESSION:  Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation. PLAN:   The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.
CHIEF COMPLAINT:   A 5-month-old boy with cough. HISTORY OF PRESENT ILLNESS:   A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it. REVIEW OF SYSTEMS:   No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom. IMMUNIZATIONS:  He received first set of shot and due for the second set on 01/17/2008. BIRTH HISTORY:   He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not. FAMILY HISTORY:  No history of asthma or lung disease. SOCIAL HISTORY:  Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said. PAST MEDICAL HISTORY:   No hospitalizations. ALLERGIES:  NO KNOWN DRUG ALLERGIES. MEDICATIONS:  No medications. History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg. GENERAL: In no acute distress. HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle. NECK: Supple. NOSE: Dry secretions. EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized. MOUTH: No pharyngitis. No ulcers. Moist mucous membranes. CHEST: Bilateral audible breath sound. No wheezes. No palpitation. HEART: Regular rate and rhythm with no murmur. ABDOMEN: Soft, nontender, and nondistended. GENITOURINARY: Tanner I male with descended testes. EXTREMITIES: Capillary refill less than 2 seconds. LABS:   White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base. ASSESSMENT:   A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive. DIAGNOSES:  Respiratory syncytial virus bronchiolitis with right otitis externa. PLAN:  Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.
CHIEF COMPLAINT:  This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma."  Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse. He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day. PAST MEDICAL HISTORY:   Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report. IMMUNIZATIONS:  Up-to-date. ALLERGIES:  Denied. MEDICATIONS: Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol. PAST SURGICAL HISTORY:  Denied. SOCIAL HISTORY:  Lives at home, here in the ED with the mother and there is no smoking in the home. FAMILY HISTORY:  No noted exposures. REVIEW OF SYSTEMS: Documented on the template. Systems reviewed on the template. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. Oxygen saturation low at 91% on room air. GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask. HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular motions are intact and conjugate. Clear TMs, nose, and oropharynx. NECK: Supple. Full painless nontender range of motion. CHEST: Tight wheezing and retractions heard bilaterally. HEART: Regular without rubs or murmurs. ABDOMEN: Soft, nontender. No masses. No hepatosplenomegaly. GENITALIA: Male genitalia is present on a visual examination. SKIN: No significant bruising, lesions or rash. EXTREMITIES: Moves all extremities without difficulty, nontender. No deformity. NEUROLOGIC: Symmetric face, cooperative, and age appropriate. MEDICAL DECISION MAKING:   The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. She is further treated in the emergency department with continued breathing treatments. At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells. Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.
CHIEF COMPLAINT:  Chronic low back, left buttock and leg pain. HISTORY OF PRESENT ILLNESS:  This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain. Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain. He states that approximately 75% of his pain is in his buttock and leg and 25% in his back. He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back. He rated his pain today as 6/10, describing it is shooting, sharp and aching. It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication. It is constant but variable in degree. It continues to affect activities and sleep at night as well as mood at times. He is currently not satisfied completely with his level of pain relief. MEDICATIONS:  Kadian 30 mg b.i.d.  Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n. ALLERGIES:   No known drug allergies. REVIEW OF SYSTEMS:   Complete multisystem review was noted and signed in the chart. SOCIAL HISTORY:   Unchanged from prior visit. PHYSICAL EXAMINATION:  Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs. He is a well-developed obese male in no acute distress. He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression. He ambulates with normal gait and has normal station. He is able to heel and toe walk. He denies any sensory changes. ASSESSMENT & PLAN:  This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. We discussed treatment options at length and he is willing to undergo a trial of Lyrica. He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime. We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him. We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him. He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.
CHIEF COMPLAINT:  Neck and lower back pain. VEHICULAR TRAUMA HISTORY:  Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released. NECK AND LOWER BACK PAIN HISTORY:  The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.