TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
CHIEF COMPLAINT:   Detox from heroin. HISTORY OF PRESENT ILLNESS:  This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse. PAST MEDICAL HISTORY:  Remarkable for chronic pain. He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain. He has previously been followed by ABC but has not seen him for several years. REVIEW OF SYSTEMS: The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses. SOCIAL HISTORY:  The patient is a smoker. Admits to heroin use, alcohol abuse as well. Also admits today using cocaine. FAMILY HISTORY:   Noncontributory. MEDICATIONS:  He has previously been on analgesics and pain medications chronically. Apparently, he just recently got out of prison. He has previously also been on Klonopin and lithium. He was previously on codeine for this pain. ALLERGIES:  NONE. PHYSICAL EXAMINATION:  VITAL SIGNS: The patient is afebrile. He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard. His respiratory rate is normal at 18. GENERAL: The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation. HEENT: Unremarkable. Pupils are actually moderately dilated about 4 to 5 mm, but reactive. Extraoculars are intact. His oropharynx is clear. NECK: Supple. His trachea is midline. LUNGS: Clear. He has good breath sounds and no wheezing. No rales or rhonchi. Good air movement and no cough. CARDIAC: Without murmur. ABDOMEN: Soft and nontender. He has multiple track marks, multiple tattoos, but no abscesses. NEUROLOGIC: Nonfocal. IMPRESSION:  MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN. ASSESSMENT AND PLAN: At this time, I think the patient can be followed up at XYZ. I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy. I do not think he needs any further workup at this time. He is discharged otherwise in stable condition.
CHIEF COMPLAINT:  Buttock abscess. HISTORY OF PRESENT ILLNESS:  This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation. PAST MEDICAL HISTORY: Diabetes type II, poorly controlled, high cholesterol. PAST SURGICAL HISTORY:  C-section and D&C. ALLERGIES:   NO KNOWN DRUG ALLERGIES. MEDICATIONS:  Insulin, metformin, Glucotrol, and Lipitor. FAMILY HISTORY:  Diabetes, hypertension, stroke, Parkinson disease, and heart disease. REVIEW OF SYSTEMS:  Significant for pain in the buttock. Otherwise negative. PHYSICAL EXAMINATION: GENERAL: This is an overweight African-American female not in any distress. VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range. HEENT: Normal to inspection. NECK: No bruits or adenopathy. LUNGS: Clear to auscultation. CV: Regular rate and rhythm. ABDOMEN: Protuberant, soft, and nontender. EXTREMITIES: No clubbing, cyanosis or edema. RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema. ASSESSMENT AND PLAN:  Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.
CHIEF COMPLAINT: Blood in toilet. HISTORY:  Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants. PAST MEDICAL HISTORY:  Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past. PAST SURGICAL HISTORY: Unknown. SOCIAL HISTORY:  No tobacco or alcohol. MEDICATIONS:  Listed in the medical records. ALLERGIES:   No known drug allergies. PHYSICAL EXAMINATION:  VITAL SIGNS: Stable. GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress. HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact. NECK: No lymphadenopathy or JVD. HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi. ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted. GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region. EXTREMITIES: No significant abnormalities. WORKUP:  CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization. ER COURSE:   Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood. ASSESSMENT:  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.
CHIEF COMPLAINT:  Nausea. PRESENT ILLNESS:  The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum. PAST MEDICAL HISTORY:  Significant for hypertension and morbid obesity, now resolved. PAST SURGICAL HISTORY:  Gastric bypass surgery in December 2007. MEDICATIONS: Multivitamins and calcium. ALLERGIES:  None known. FAMILY HISTORY: Positive for diabetes mellitus in his father, who is now deceased. SOCIAL HISTORY:  He denies tobacco or alcohol. He has what sounds like a data entry computer job. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION:   His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically. STUDIES:   His white blood cell count is 8.4 with 79 segs. His hematocrit is 41. His electrolytes are normal. His bilirubin is 2.8. His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239. ASSESSMENT:  Choledocholithiasis, ? cholecystitis. PLAN:  He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands.
CHIEF COMPLAINT:  Possible exposure to ant bait. HISTORY OF PRESENT ILLNESS:   This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type. PAST MEDICAL HISTORY:  Negative. Generally very healthy. REVIEW OF SYSTEMS:  The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth. MEDICATIONS:  None. ALLERGIES:  NONE. PHYSICAL EXAMINATION:  VITAL SIGNS: The patient was afebrile. Stable vital signs and normal pulse oximetry. GENERAL: The child is very active, cheerful youngster, in no distress whatsoever. HEENT: Unremarkable. Oral mucosa is clear, moist, and well hydrated. I do not see any evidence of any sort of liquid on the face. Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso. Apparently, she had some on her hands that has been wiped off. EMERGENCY DEPARTMENT COURSE:   I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case. IMPRESSION:  Exposure to ant bait. PLAN:  At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. So, the patient is discharged in stable condition.
CHIEF COMPLAINT:   Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting. HISTORY OF PRESENT ILLNESS:  AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anything, and has vomited 8 times. AF reports 10/10 pain in the LLQ. PAST MEDICAL HISTORY:   AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain. Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY:  AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:   None. ALLERGIES:   Iodine, IV contrast (anaphylaxis), and seafood/shellfish. FAMILY HISTORY:   Noncontributory. SOCIAL HISTORY:   AF was born and raised in San Francisco. His father was an alcoholic. He currently lives with his sister, and does not work; he collects a pension. HEALTH-RELATED BEHAVIORS:   AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day. REVIEW OF SYSTEMS:  Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia. PHYSICAL EXAM: Vital Signs: T: 37.1
CHIEF COMPLAINT:  Nausea and abdominal pain after eating. GALL BLADDER HISTORY:  The patient is a 36 year old white female. Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC. PAST MEDICAL HISTORY:  No significant past medical problems. PAST SURGICAL HISTORY:  Diagnostic laparoscopic exam for pelvic pain/adhesions. ALLERGIES:  No known drug allergies. CURRENT MEDICATIONS:  No current medications. OCCUPATIONAL /SOCIAL HISTORY:  Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs. FAMILY MEDICAL HISTORY:  There is no significant, contributory family medical history. OB GYN HISTORY:  LMP: 5/15/1999. Gravida: 1. Para: 1. Date of last pap smear: 1/15/1998. REVIEW OF SYSTEMS: Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax. Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment. Neurological: Patient admits to symptoms of seizures and ataxia. Skin: Denies scaling, rashes, blisters, photosensitivity. PHYSICAL EXAMINATION: Appearance: Healthy appearing. Moderately overweight. HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions. Neck: Neck mobile. Trachea is midline. Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy. Breast: Normal appearing breasts bilaterally, nipples everted. No nipple discharge, skin changes. Chest: Normal breath sounds heard bilaterally without rales or rhonchi. No pleural rubs. No scars. Cardiovascular: Regular heart rate and rhythm without murmur or gallop. Abdominal: Bowel sounds are high pitched. Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal. Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions. IMPRESSION DIAGNOSIS:   Gall Bladder Disease. Abdominal Pain. DISCUSSION:  Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure. PLAN:  We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram. MEDICATIONS PRESCRIBED:
CHIEF COMPLAINT:   GI bleed. HISTORY OF PRESENT ILLNESS:   The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The patient denied any shortness of breath. No chest pain. No GI complaints. The patient was admitted to ABCD for further evaluation. PAST MEDICAL HISTORY: Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism. PHYSICAL EXAMINATION: GENERAL: The patient is in no acute distress. VITAL SIGNS: Stable. HEENT: Benign. NECK: Supple. No adenopathy. LUNGS: Clear with good air movement. HEART: Irregularly regular. No gallops. ABDOMEN: Positive bowel sounds, soft, and nontender. No masses or organomegaly. EXTREMITIES: 1+ lower extremity edema bilaterally. HOSPITAL COURSE:  The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis. Colonoscopy did reveal diverticulosis as well as polyp, which was resected. The patient tolerated the procedure well. She was transfused, and prior to discharge hemoglobin was stable at 10.7. The patient was without further GI complaints. Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume. The patient was discharged with outpatient PMD, GI, and Cardiology followup. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Anemia. 3. Atrial fibrillation. 4. Non-insulin-dependent diabetes mellitus. 5. Hypertension. 6. Hypothyroidism. 7. Asthma. CONDITION UPON DISCHARGE:  Stable. MEDICATIONS:  Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d.  KCl 20 mEq daily, Lasix 40 mg b.i.d.  atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily. ALLERGIES:   None. DIET:  1800-calorie ADA. ACTIVITY:  As tolerated. FOLLOWUP:  The patient to hold Coumadin through weekend. Followup CBC and INR were ordered. Outpatient followup as arranged.
CHIEF COMPLAINT:  Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:  Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: Celecoxib (rash). SOCIAL HISTORY:  Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:  Non-contributory. PHYSICAL EXAM: Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: CBC: WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.
CHIEF COMPLAINT:  Sinus problems. SINUSITIS HISTORY:  The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning. REVIEW OF SYSTEMS: ROS General: General health is good. ROS ENT: As noted in history of present Illness listed above. ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc. ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements. ROS Respiratory: Complaints include coughing. ROS Neurological: Patient complains of headaches. All other systems are negative. PAST SURGICAL HISTORY:  Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:  Negative. PAST SOCIAL HISTORY:  Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home. FAMILY MEDICAL HISTORY:  Family history of allergies and hypertension. CURRENT MEDICATIONS:  Claritin. Dilantin. PREVIOUS MEDICATIONS UTILIZED:  Rhinocort Nasal Spray. EXAM: Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation. Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus. Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic. Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles. Exam Facial: There is bilateral maxillary sinus tenderness to palpation. X-RAY / LAB FINDINGS:  Water's view x-ray reveals bilateral maxillary mucosal thickening. IMPRESSION:  Acute maxillary sinusitis (461.0). Snoring (786.09). MEDICATION:  Augmentin. 875 mg bid. MucoFen 800 mg bid. PLAN: