TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
CHIEF COMPLAINT:  Chronic otitis media, adenoid hypertrophy. HISTORY OF PRESENT ILLNESS:  The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions. He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy. He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes. ALLERGIES: None. MEDICATIONS:   Antibiotics p.r.n. FAMILY HISTORY:  Diabetes, heart disease, hearing loss, allergy and cancer. MEDICAL HISTORY:  Unremarkable. SURGICAL HISTORY:  None. SOCIAL HISTORY:  Some minor second-hand tobacco exposure. There are no pets in the home. PHYSICAL EXAMINATION:   Ears are well retracted, immobile. Tympanic membranes with effusions present bilaterally. No severe congestions, thick mucoid secretions, no airflow. Oral cavity: Oropharynx 2 to 3+ tonsils. No exudates. Floor of mouth and tongue are normal. Larynx and pharynx not examined. Neck: No nodes, masses or thyromegaly. Lungs: Reveal rare rhonchi, otherwise, clear. Cardiac exam: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender. Positive bowel sounds. Neurologic exam: Nonfocal. IMPRESSION: Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy. PLAN:  The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.
CHIEF COMPLAINT:   Right ear pain with drainage. HISTORY OF PRESENT ILLNESS:   This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea. PHYSICAL EXAM: General: He is alert in no distress. Vital Signs: Temperature: 99.1 degrees. HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular. No murmur. ASSESSMENT: 1. Right otitis media. 2. Right otorrhea. PLAN:   Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup.
CHIEF COMPLAINT:   Dental pain. HISTORY OF PRESENT ILLNESS:   This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation. PAST MEDICAL HISTORY:  Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease. She has chronic pain in general and is followed by Dr. X. REVIEW OF SYSTEMS:  Otherwise, unremarkable. Has not noted any fever or chills. However she, as mentioned, does note the dental discomfort with increasing swelling and pain. Otherwise, unremarkable except as noted. CURRENT MEDICATIONS:  Please see list. ALLERGIES:  IODINE, FISH OIL, FLEXERIL, BETADINE. PHYSICAL EXAMINATION:  VITAL SIGNS: The patient was afebrile, has stable and normal vital signs. The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain. HEENT: Unremarkable. I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region. There is no neck adenopathy. Oral mucosa is moist and well hydrated. Dentition looks to be in reasonable condition. However, she definitely is tender to percussion on the left lower first premolar. I do not see any huge cavity or anything like that. No real significant gingival swelling and there is no drainage noted. None of the teeth are tender to percussion. PROCEDURE:   Dental nerve block. Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia. I have then written a prescription for penicillin and Vicodin for pain. IMPRESSION:  ACUTE DENTAL ABSCESS. ASSESSMENT AND PLAN: The patient needs to follow up with the dentist for definitive treatment and care. She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics. However, outpatient followup should be adequate. She is discharged in stable condition.
CHIEF COMPLAINT:  The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:  The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:  None. ,CURRENT MEDICATIONS:  Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:  The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: FINAL DIAGNOSIS: 1. Evaluation of chest pain. ,2. Possible esophageal reflux.
CHIEF COMPLAINT:   Status post motor vehicle accident. HISTORY OF PRESENT ILLNESS:  The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle. He denies loss of consciousness, although the EMT people report that he did have loss of consciousness. The patient was stable en route. Upon arrival, he complained of headache. PAST MEDICAL HISTORY:   Medical: None. Surgical: None. REVIEW OF SYSTEMS:  CARDIAC: No history. PULMONARY: Some morning cough. (Patient is a smoker.),MEDICATIONS:   None. ALLERGIES:   ALLERGIC TO PENICILLIN, CAUSES SKIN RASH. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°. HEENT: Contusion over right occipital area. Tympanic membranes benign. NECK: Nontender. CHEST: Atraumatic, nontender. LUNGS: Clear to auscultation and percussion. ABDOMEN: Flat, soft, and nontender. BACK: Atraumatic, nontender. PELVIS: Stable,EXTREMITIES: Contusion over right forearm. No bone deformity or crepitus. RECTAL: Normal sphincter tone; guaiac negative. NEUROLOGIC: Glasgow coma scale 15. Pupils equal, round, reactive to light. Patient moves all 4 extremities without focal deficit. LABORATORY DATA:  Serial hematocrits 42.4, and 40.4. White blood count 6.3. Ethanol: None. Amylase 66. Urinalysis normal. PT 12.6, PTT 29. Chem-7 panel within normal limits. X-rays of cervical spine and lumbosacral spine within normal limits. X-rays of pelvis and chest within normal limits. ASSESSMENT: 1. Closed head injury. 2. Rule out intra-abdominal injury. PLAN:   The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.
CHIEF COMPLAINT:  Altered mental status. HISTORY OF PRESENT ILLNESS:  This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding. The patient was found by the 8-year-old sister in the bathroom. He was laying down on one side, and he was crying and moaning. The sibling went and told the parents. The parents rushed to the bathroom, they found him crying, and he was not moving the left side of his body. He was initially alert, but his alertness diminished. They decided to take him to the emergency room in Hospital, where a CT was done on his head, which showed a 4 x 4 x 2.5 cm bleed. The emergency physician called our emergency room, and I decided to involve Neurosurgery, Mr. X, the physician assistant, who is on call for the Neurosurgery Services. Collectively, they have made arrangements with the ICU attendings to have the child transported to our emergency room. For a small stop, I am obtaining an MRI and then admitting to the ICU. History was taken from the parents. He had a history of gastroesophageal reflux disease, otherwise, a healthy child. MEDICATIONS:  None. ALLERGIES:   No known drug allergies. PAST SURGICAL HISTORY:  He had only tympanostomy tubes placed. FAMILY MEDICAL HISTORY:   Unremarkable. PHYSICAL EXAMINATION: GENERAL: He was brought by our transport team. While en route, he was not as alert as he was. He was still oriented. He had to be stimulated via sternal rub to wake up, and saturation went down to the 80s, and he was started on nasal cannula, and code 3 was initiated, and he was rushed to our emergency room. When I saw him, he was lethargic, but arousable. He could recognize where he was, and he could recognize also his parents well. HEENT: Pupils are 4 mm reactive to direct and indirect light. No signs of trauma is seen on the head. Throat is clear. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft. NEUROLOGIC: He has left-sided weakness, but his cranial nerves II through XII are grossly intact. EMERGENCY DEPARTMENT COURSE:  In the emergency room, at the time when I saw him, Dr. Y and Dr. Z were from the ICU and Anesthesia Services arrived also, and they evaluated the patient with me and pretty much they took care of the patient. They decided to give him a dose of IV mannitol. I ordered his labs, type and cross. CBC is 15.6 white blood cell count, hemoglobin 12.8. PT/PTT were ordered due to the bleed, which was seen intracerebrally. They were 13.1 and 24.5 respectively. Blood gas, I-STAT pH 7.36, pCO2 is 51. This was a venous specimen. The ICU attendings decided to do a rapid sequence intubation. This was done in our emergency room by Dr. Y and Dr. Z. The patient was sent to the MRI, and from where he was going to be admitted to the ICU in critical condition. DIFFERENTIAL DIAGNOSES:  Arteriovenous malformation, stroke, traumatic injury. IMPRESSION:  Intracerebral hemorrhage of uncertain etiology to be determined while inpatient. TIME SPENT:   I spent 30 minutes critical care time with the patient excluding any procedures.
CHIEF COMPLAINT:  Chest pain. HISTORY OF PRESENT ILLNESS:   The patient is a 40-year-old white male who presents with a chief complaint of "chest pain". The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour. The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed. REVIEW OF SYSTEMS:   All other systems reviewed & are negative. PAST MEDICAL HISTORY:   Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC. SOCIAL HISTORY:  Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker. FAMILY HISTORY:  Positive for coronary artery disease (father & brother). MEDICATIONS:  Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain. ALLERGIES:  Penicillin. PHYSICAL EXAM:  The patient is a 40-year-old white male. General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates