TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
IDENTIFICATION OF PATIENT:  The patient is a 34-year-old Caucasian female. CHIEF COMPLAINT:   Depression. HISTORY OF PRESENT ILLNESS:   The patient's depression began in her teenage years. Sleep has been poor, for multiple reasons. She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes. The patient tends to feel irritable, and has crying spells. She sometimes has problems with motivation. She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change. Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine. She does not have suicidal thoughts. ,The patient also has what she describes as going into a "panic mode."  During these times, she feels as if her whole body is going to explode. She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom. These spells may last a couple of hours, but once lasted for about two day. She does not get chest pain. These attacks tend to be precipitated by bills that cannot be paid, or being on a "time crunch." ,PSYCHIATRIC HISTORY:   The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking. Although she was able to cut down on tobacco usage, the depression has been more poorly controlled. She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times. At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do. She has never been hospitalized for psychiatric purposes. She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services. She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility. SUBSTANCE ABUSE HISTORY: Caffeine: The patient has two or three drinks per day of tea or Diet Pepsi. Tobacco: She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day. She is still committed to quitting. Alcohol: Denied. Illicit drugs: Denied. In her earlier years, someone once put some unknown drug in her milk, and she "came to" when she was dancing on the table in front of the school nurse. MEDICAL HISTORY/REVIEW OF SYSTEMS: Constitutional: See History of Present Illness. No recent fever or sweats.
IDENTIFYING DATA:   The patient is a 36-year-old Caucasian male. CHIEF COMPLAINT:   The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted. HISTORY OF PRESENT ILLNESS:   The patient has been receiving services at this facility previously, under the care of ABC, M.D.  and later XYZ, M.D. Historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works. He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past, probably in high school, the patient recalled being more figidity than now. He tensed to feel anxious. Sleep has been highly variable. He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. Appetite has been good. He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed. His energy level is "better now," but this was very problematic in the past. He has problems with motivation. In the past, he had passing thoughts of suicide, but this is no longer a problem. PSYCHIATRIC HISTORY:   The patient has never been hospitalized for psychiatric purposes. His only treatment has been at this facility. He tried Adderall for a time, and it helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m.  but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the other half of the tablet in the afternoon.
IDENTIFYING DATA:  The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. CHIEF COMPLAINT:  "I am not sure." The patient has poor insight into hospitalization and need for treatment. HISTORY OF PRESENT ILLNESS:  The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas. According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks. The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle. The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail. The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold). PAST PSYCHIATRIC HISTORY:  History of schizophrenia, chronic paranoid. The patient as noted has been treated in Houston but has not had recent treatment or medications. PAST MEDICAL HISTORY: No acute medical problems noted. CURRENT MEDICATIONS:  None. The patient was most recently treated with Invega and Abilify according to his records. FAMILY SOCIAL HISTORY:  The patient resides with his father in Houston. The patient has no known history of substances abuse. The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold. FAMILY PSYCHIATRIC HISTORY:   Need to increase database. MENTAL STATUS EXAMINATION: Attitude: Calm and cooperative. Appearance: Shows poor hygiene and grooming. Psychomotor: Behavior is within normal limits without agitation or retardation. No EPS or TDS noted. Affect: Is suspicious. Mood: Anxious but cooperative. Speech: Shows normal rate and rhythm. Thoughts: Disorganized,Thought Content: Remarkable for paranoia "they want to hurt me.",Psychosis: The patient endorses paranoid delusions as above. The patient denies auditory hallucinations. Suicidal/Homicidal Ideation: The patient denies on admission. Cognitive Assessment: Grossly intact. The patient is alert and oriented x 3. Judgment: Poor, shown by noncompliance with treatment. Assets: Include stable physical status. Limitations: Include recurrent psychosis. FORMULATION: The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment. INITIAL IMPRESSION: AXIS I: Schizophrenia, chronic paranoid. AXIS II: None. AXIS III: None. AXIS IV: Severe. AXIS V: 10. ESTIMATED LENGTH OF STAY:  12 days. PLAN: The patient will be restarted on Invega and Abilify for psychosis. The patient will also be continued on Cogentin for EPS. Increased database will be obtained.
CHIEF COMPLAINT:  Mental status changes after a fall. HISTORY:  Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. She was very confused, incomprehensible speech, and was not responding appropriately. She was transported here stable, with no significant changes. She ultimately upon arrival here was unchanged in that she was not responding appropriately. She would have garbled speech, somewhat inappropriate at times, and unable to follow commands. No other history was able to be obtained. All pertinent history is documented within the records. Physical examination also documented in the records, essentially as above. PHYSICAL EXAMINATION:  HEENT: Without any obvious signs of trauma. Pupils are equal and reactive. Extraocular movements are difficult to assess with her eyes closed, but she will open to voice. TMs, canals are normal without any signs of hemotympanum. Nasal mucosa and oropharynx are normal. NECK: Nontender, full range of motion, was not examined initially, a collar was placed. HEART: Regular. LUNGS: Clear. CHEST/BACK/ABDOMEN: Without trauma. SKIN: With multiple excoriations from scratching and itching. NEUROLOGIC: Otherwise she has good sensation, withdrawals to pain. When lifting the arm, she will hold them up and draw, let them down slowly. With movement of the legs, she did straighten them back out slowly. DTRs were intact and equal bilaterally. Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change. LABORATORY DATA:  CT scan of the head was negative as was cervical spine. She has a history of being on Coumadin. Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands. CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3. ASSESSMENT AND PLAN:  Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation. I have discussed this with her son, he agrees. Otherwise, she has improved significantly. The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.
CHIEF COMPLAINT:   Falls at home. HISTORY OF PRESENT ILLNESS:   The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for "attention."  The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she "tripped" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI. PHYSICAL EXAMINATION: GENERAL: The patient is pleasant 82-year-old female in no acute distress. VITAL SIGNS: Stable. HEENT: Negative. NECK: Supple. Carotid upstrokes are 2+. LUNGS: Clear. HEART: Normal S1 and S2. No gallops. Rate is regular. ABDOMEN: Soft. Positive bowel sounds. Nontender. EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender. NEUROLOGICAL: Grossly nonfocal. HOSPITAL COURSE:  A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls. DISCHARGE DIAGNOSES: 1. Falls ,2. Anxiety and depression. 3. Hypertension. 4. Hypercholesterolemia. 5. Coronary artery disease. 6. Osteoarthritis. 7. Chronic obstructive pulmonary disease. 8. Hypothyroidism. CONDITION UPON DISCHARGE:  Stable. DISCHARGE MEDICATIONS:  Tylenol 650 mg q.6h. p.r.n.  Xanax 0.5 q.4h. p.r.n.  Lasix 80 mg daily, Isordil 10 mg t.i.d.  KCl 20 mEq b.i.d.  lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n.  Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n.  Advair 250/50 one puff b.i.d.  Senokot one tablet b.i.d.  Timoptic one drop OU daily, and verapamil 80 mg b.i.d. ALLERGIES:  None. ACTIVITY:  Per PT. FOLLOW-UP:  The patient discharged to a skilled nursing facility for further rehabilitation.
CHIEF COMPLAINT:  Foot pain. HISTORY OF PRESENT ILLNESS:  This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour prior to this injury. Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. He is able to bear weight; however, complains of pain in his toes. The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. According to the patient, he was at his baseline state of health prior to this acute event. PAST MEDICAL HISTORY:  Significant for attention deficit hyperactivity disorder. PAST SURGICAL HISTORY: Positive for wisdom tooth extraction. FAMILY HISTORY:  Noncontributory. SOCIAL HISTORY: He does not use alcohol, tobacco or illicit drugs. He plays water polo for the school team. IMMUNIZATION HISTORY:  All immunizations are up-to-date for age. REVIEW OF SYSTEMS:  The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative. PRESENT MEDICATIONS:  Provigil, Accutane and Rozerem. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: This is a pleasant white male in no acute distress. VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits. HEENT: Negative for acute evidence of trauma, injury or infection. LUNGS: Clear. HEART: Regular rate and rhythm with S1 and S2. ABDOMEN: Soft. EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses are intact. The left foot notes superficial avulsion lacerations to the third and fourth digit. There are no subungual hematomas. Range of motion is decreased secondary to pain. No obvious fractures identified. BACK EXAM: Nontender. NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit. RADIOLOGY:  AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries. On reevaluation, the patient was resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair. DISCHARGE MEDICATIONS:  Darvocet. The patient's condition at discharge was stable. All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. The patient/family understood the instructions and was discharged without further incident.
CHIEF COMPLAINT:   Ankle pain. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to move or bear weight. No other injuries noted. He does not think he has had injuries to his ankle in the past. PAST MEDICAL HISTORY:  None. PAST SURGICAL HISTORY:  None. SOCIAL HISTORY:  He does not drink or smoke. ALLERGIES:  Unknown. MEDICATIONS:  Adderall and Accutane. REVIEW OF SYSTEMS:  As above. Ten systems reviewed and are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air. GENERAL:
ADMISSION DIAGNOSIS:  Left hip fracture. CHIEF COMPLAINT:  Diminished function, secondary to the above. HISTORY:  This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions. PAST MEDICAL HISTORY:  Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties. ALLERGIES:   Zyloprim, penicillin, Vioxx, NSAIDs. CURRENT MEDICATIONS,1. Heparin. 2. Albuterol inhaler. 3. Combivent. 4. Aldactone. 5. Doxepin. 6. Xanax. 7. Aspirin. 8. Amiodarone. 9. Tegretol. 10. Synthroid. 11. Colace. SOCIAL HISTORY:  Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility. REVIEW OF SYSTEMS:   Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain. PHYSICAL EXAMINATION,HEENT: Oropharynx clear. CV: Regular rate and rhythm without murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender, nondistended. Bowel sounds positive. EXTREMITIES: Without clubbing, cyanosis, or edema. NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out. IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty. 2. History of panic attack, anxiety, depression. 3. Myocardial infarction with stent placement. 4. Hypertension. 5. Hypothyroidism. 6. Subdural hematoma. 7. Seizures. 8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency. 9. Renal insufficiency. 10. Recent pneumonia. 11. O2 requiring. 12. Perioperative anemia. PLAN:  Rehab transfer as soon as medically cleared.
ADMITTING DIAGNOSIS:  Encephalopathy related to normal-pressure hydrocephalus. CHIEF COMPLAINT:   Diminished function secondary to above. HISTORY: This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed. He had a shunt placed and was stabilized medically. He has gotten a return of function to the legs and was started on some early therapy. Significant functional limitations have been identified and ongoing by the rehab admission team. Significant functional limitations have been ongoing. He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home. PAST MEDICAL HISTORY:  Positive for prostate cancer, intermittent urinary incontinence and left hip replacement. ALLERGIES:  No known drug allergies. CURRENT MEDICATIONS,1. Tylenol as needed. ,2. Peri-Colace b.i.d. SOCIAL HISTORY:   He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family  relatives intermittently available. Goal is to return home to an independent fashion to that home setting. FUNCTIONAL HISTORY:  Prior to admission was independent with activities of daily living and ambulatory skills. Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living. Memory at minimal assist. Walking at supervision.  REVIEW OF SYSTEMS: Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently. He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain. PHYSICAL EXAMINATION,VITAL SIGNS: The patient is afebrile with vital signs stable. HEENT: Oropharynx clear, extraocular muscles are intact. CARDIOVASCULAR: Regular rate and rhythm, without murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender, nondistended,  positive bowel sounds. EXTREMITIES: Without clubbing, cyanosis, or edema. The calves are soft and nontender bilaterally. NEUROLOGIC: No focal, motor or sensory losses through the lower extremities. He moves upper and lower extremities well. Bulk and tone normal in the upper and lower extremities. Cognitively showing intact with appropriate receptive and expressive skills. IMPRESSION ,