TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
CHIEF COMPLAINT:  Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms. HPI - LUMBAR SPINE:  The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset. PAST SPINE HISTORY:  Unremarkable. PRESENT LUMBAR SYMPTOMS:  Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset. PRESENT RIGHT LEG SYMPTOMS:  Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset. PRESENT LEFT LEG SYMPTOMS:  None. NEUROLOGIC SIGNS/SYMPTOMS:  The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.
CHIEF COMPLAINT:  Left knee pain and stiffness. HISTORY OF PRESENT ILLNESS:  The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X. PAST MEDICAL HISTORY:  Hypertension. PRIOR SURGERIES: 1. Inguinal hernia on the left. 2. Baker's cyst. 3. Colon cancer removal. 4. Bilateral knee scopes. 5. Right groin hernia. 6. Low back surgery for spinal stenosis. 7. Status post colon cancer second surgery. MEDICATIONS: 1. Ambien 12.5 mg nightly. 2. Methadone 10 mg b.i.d. 3. Lisinopril 10 mg daily. IV MEDICATIONS FOR PAIN: Demerol appears to work the best. ALLERGIES:  Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction. REVIEW OF SYSTEMS: He does have paresthesias down into his thighs secondary to spinal stenosis. SOCIAL HISTORY:  Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees. HABITS:  No tobacco or alcohol. Chewed until 2003. RECREATIONAL PURSUITS: Golfs, gardens, woodworks. FAMILY HISTORY: 1. Cancer. 2. Coronary artery disease. PHYSICAL EXAMINATION: GENERAL APPEARANCE: A pleasant, cooperative 57-year-old white male. VITAL SIGNS: Height 5' 9", weight 167. Blood pressure 148/86. Pulse 78 per minute and regular. HEENT: Unremarkable. Extraocular movements are full. Cranial nerves II-XII intact. NECK: Supple. CHEST: Clear. CARDIOVASCULAR: Regular rhythm. Normal S1 and 2. ABDOMEN: No organomegaly. No tenderness. Normal bowel sounds. NEUROLOGIC: Intact. MUSCULOSKELETAL: Left knee reveals a range of -10 degrees extension, 126 flexion. His extensor mechanism is intact. There is mild varus. He has good stability at 30 degrees of flexion. Lachman's and posterior drawer are negative. He has good muscle turgor. Dorsalis pedis pulse 2+. DIAGNOSTICS: X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right. IMPRESSION: 1. Bilateral knee degenerative joint disease. 2. Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.
CHIEF COMPLAINT:  Left foot pain. HISTORY:  XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:  He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender. RADIOGRAPHS:  Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:   Left Chopart joint sprain. PLAN:   I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.
CHIEF COMPLAINT:   Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint. HISTORY OF OCCUPATIONAL INJURY OR ILLNESS:   The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. This has been going on for several months. He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain. He is referred over here for evaluation regarding that. SIGNIFICANT PAST MEDICAL AND SURGICAL HISTORY: General health/review of systems: See H&P. ,Allergies: See H&P. Medications: See H&P. Social History: See H&P. Family History: See H&P. Previous Hospitalizations: See H&P. CLINICAL ASSESSMENT AND FINDINGS: Musculoskeletal: Shows point tenderness to palpation to the right middle finger A1 pulley. The right index finger has some small soreness at the PIP joint, but at this time no obvious mucocyst. He has flexion/extension of his fingers intact. There is no crepitation at the wrist, forearm, elbow or shoulder with full range of motion. Contralateral arm exam for comparison reveals no focal findings. Neurological: APB, EPL and first dorsal interosseous 5/5. LABORATORY, RADIOGRAPHIC, AND/OR IMAGING TESTS ORDERS & RESULTS: Special lab studies: CLINICAL IMPRESSION: 1. Tendinitis, left middle finger. 2. PIP joint synovitis and mucocyst, but controlled on nonoperative treatment. 3. Middle finger trigger, failed nonoperative treatment, requiring a trigger finger release to the right middle finger. EVALUATION/TREATMENT PLAN:   Risks, benefits and alternatives were discussed. All questions were answered. No guarantees were made. We will schedule for surgery. We would like to move forward in order to help him significantly improve since he has failed injections. All questions were answered. Followup appointment was given.
CHIEF COMPLAINT:   Left knee pain. SUBJECTIVE:  This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. Rates her pain in her knee as a 10/10. She does alternate ice and heat. She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief. ALLERGIES,1. PENICILLIN. 2. KEFLEX. 3. BACTRIM. 4. SULFA. 5. ACE BANDAGES. MEDICATIONS,1. Toprol. 2. Xanax. 3. Advair. 4. Ventolin. 5. Tylenol No. 3. 6. Advil. REVIEW OF SYSTEMS:   Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first. Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below. PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches. GENERAL: This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect. She is well developed, well nourished, appears her stated age. EXTREMITIES: Orthopedic evaluation of the left knee reveals there to be well-healed portholes. She does have some medial joint line swelling. Negative ballottement. She has significant pain to palpation of the medial joint line, none of the lateral joint line. She has no pain to palpation on the popliteal fossa. Range of motion is approximately -5 degrees to 95 degrees of flexion. It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. She has a click with McMurray. Negative anterior-posterior drawer. No varus or valgus instability noted. Positive patellar grind test. Calf is soft and nontender. Gait is stable and antalgic on the left. ASSESSMENT,1. Osteochondral defect, torn meniscus, left knee. 2. Obesity. PLAN:  I have encouraged the patient to work on weight reduction, as this will only benefit her knee. I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction. She questions whether she needs a total knee; I don't believe she needs total knee replacement. She may, however, at some point need an arthroscopy. I have encouraged her to start formal physical therapy and a home exercise program. Will use ice or heat p.r.n. I have given her refills on Tylenol No. 3, Flector patch, and Relafen not to be taken with any other anti-inflammatory. She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily. She will follow up in our office in four weeks. If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy. The patient shows a good understanding of this treatment plan and agrees.
CHIEF COMPLAINT:   Right ankle sprain. HISTORY OF PRESENT ILLNESS:  This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time. PAST MEDICAL HISTORY:  Hypertension and anxiety. PAST SURGICAL HISTORY:  None. MEDICATIONS:  She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses. ALLERGIES:   No known drug allergies. SOCIAL HISTORY:  The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time. FAMILY HISTORY:   Noncontributory. REVIEW OF SYSTEMS: Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea. PHYSICAL EXAM: GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A. NECK: Supple. No lymphadenopathy. No thyromegaly. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. No murmurs. ABDOMEN: Non-distended, nontender, normal active bowel sounds. EXTREMITIES: No Clubbing, No Cyanosis, No edema. MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle. DIAGNOSTIC DATA:  X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending.  ,IMPRESSION:   Right ankle sprain. PLAN: 1. Motrin 800 mg t.i.d. 2. Tylenol 1 gm q.i.d. as needed. 3. Walking cast is prescribed. 4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.
IDENTIFICATION:  The patient is a 15-year-old female. CHIEF COMPLAINT:  Right ankle pain. HISTORY OF PRESENT ILLNESS:   The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown. REVIEW OF SYSTEMS:   Otherwise negative except as stated above. PAST MEDICAL HISTORY:   None. PAST SURGICAL HISTORY:  None. MEDICATIONS:   None. SOCIAL HISTORY:  Mother appears loving and caring. There is no evidence of abuse. ALLERGIES:   No known drug allergies. PHYSICAL EXAMINATION:  General: The patient is alert and oriented x4 in mild distress without diaphoresis. She is nonlethargic and nontoxic. Vitals: Within normal limits. The right ankle shows no significant swelling. There is no ecchymosis. There is no significant tenderness to palpation. The ankle has good range of motion. The foot is nontender. Vascular: +2/2 dorsalis pedis pulse. All compartments are soft. Capillary refill less than 2 seconds. DIAGNOSTIC TEST:   The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation. MEDICAL DECISION MAKING:  Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home. She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain. She may need to see a specialist, but at this time this is a very mild ankle injury. There is no significant physical finding, and I foresee no complications. I will give her 1 week off of PE. MORBIDITY/MORTALITY:   I expect no acute complications. A full medical screening exam was done and no emergency medical condition exists upon discharge. COMPLEXITY:   Moderate. The differential includes fracture, contusion, abrasion, laceration, and sprain. ASSESSMENT:   Right ankle sprain. PLAN:   Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist. She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.
CHIEF COMPLAINT:   Achilles ruptured tendon. HISTORY:   Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola. He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg. He was seen locally and diagnosed with an Achilles tendon rupture. He has been on crutches and has been nonweightbearing since that time. He had no pain prior to his injury. He has had some swelling that is mild. He has just been on aspirin a day due to his traveling time. Pain currently is minimal. PAST MEDICAL HISTORY:   Denies diabetes, cardiovascular disease, or pulmonary disease. CURRENT MEDICATIONS:   Malarone, which is an anti-malarial. ALLERGIES:   NKDA,SOCIAL HISTORY:   He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco. PHYSICAL EXAM:   Pleasant gentleman in no acute distress. He has some mild swelling on the right ankle and hindfoot. He has motion that is increased into dorsiflexion. He has good plantarflexion. Good subtalar, Chopart and forefoot motion. His motor function is intact although weak into plantarflexion. Sensation is intact. Pulses are strong. In the prone position, he has diminished tension on the affected side. There is some bruising around the posterior heel. He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him. Squeezing the calf causes no plantarflexion of the foot. RADIOGRAPHS:   Of his right ankle today show a preserved joint space. I don't see any evidence of fracture noted. Radiographs of the heel show no fracture noted with good alignment. IMPRESSION:   Right Achilles tendon rupture. PLAN:   I have gone over with Mr. XYZ the options available. We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment. Based on his age and his activity level, I think his best option is for operative fixation. We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery. We have discussed doing this as an outpatient procedure. He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼" lift. He understands a 6-9 month return to sports overall. He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola. Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1" lift also. He can weight bear until surgery and we will have it set up this week. His questions were all answered today.
CHIEF COMPLAINT:   This 26-year-old male presents today for a complete eye examination. ALLERGIES:   Patient admits allergies to aspirin resulting in disorientation, GI upset. MEDICATION HISTORY:   Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID). PMH:  Past medical history is unremarkable. PAST SURGICAL HISTORY:   Patient admits past surgical history of (+) appendectomy in 1989. SOCIAL HISTORY:   Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. FAMILY HISTORY:   Unremarkable. REVIEW OF SYSTEMS: Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision. Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness. Musculoskeletal: (-) joint or musculoskeletal symptoms. EYE EXAM:   Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus. Pupils: Pupil exam reveals round and equally reactive to light and accommodation. Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Visual Fields: Confrontation VF exam reveals full to finger confrontation O.U. IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving. Keratometry: OD: K1 35.875K2 35.875,OS: K1 35.875K2 41.875,Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet. Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance. Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber. Lens: Bilateral lenses reveals transparent lens that is in normal position. Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping. Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color. VISUAL ACUITY: Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15. REFRACTION: Lenses - final: OD: +0.50 +1.50 X 125 Prism 1.75,OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add: OD: +1.00 OS: +1.00,OU: Far VA 20/25,TEST RESULTS:   No tests to report at this time. IMPRESSION:   Eye and vision exam normal. PLAN:   Return to clinic in 12 month (s). PATIENT INSTRUCTIONS: