TigerResearch/tigerbot-mt-note-generation-en huggingface dataset:
CHIEF COMPLAINT:  Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS:  This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics. She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago. She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty. ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and small joints. ,MEDICATIONS:  Prednisone 7.5 mg p.o. q.d.  Premarin 0.125 mg p.o. q.d.  and Dolobid 1000 mg p.o. q.d.  recently discontinued because of questionable allergic reaction. HCTZ 25 mg p.o. q.o.d.  Oral calcium supplements. In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: None by history. ,FAMILY/SOCIAL HISTORY:  Noncontributory. PHYSICAL EXAMINATION:  This is a chronically ill appearing female, alert, oriented, and cooperative. She moves with great difficulty because of fatigue and malaise. Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22. HEENT: Normocephalic. No scalp lesions. Dry eyes with conjuctival injections. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosion of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. Tonsils not enlarged. No visible exudate. She has difficulty opening her mouth because of pain. SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown. She has some fissuring in the buttocks crease. PULMONARY: Clear to percussion in auscultation. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Protuberant no organomegaly and positive bowel sounds. NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia. MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis. She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+. I feel no pulse distally in either leg. ,PROBLEMS: 1. Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome. 2. Rheumatoid Arthritis class 3, stage 4. 3. Flare of arthritis after discontinuing methotrexate. 4. Osteoporosis with compression fracture. 5. Mild dehydration. 6. Nephrolithiasis. PLAN:  Patient is admitted for IV hydration and treatment of oral ulcerations. We will obtain a dermatology consult. IV leucovorin will be started, and the patient will be put on high-dose corticosteroids.
CHIEF COMPLAINT:  Mental changes today. HISTORY OF PRESENT ILLNESS:  This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range. PAST MEDICAL HISTORY:  Diabetes, hypertension. PAST SURGICAL HISTORY:   None. FAMILY HISTORY:  Unremarkable. ALLERGIES:  No known drug allergies. MEDICATIONS:   In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day. SOCIAL HISTORY: The patient is a Mazatlan, Mexico resident, visiting her son here. PHYSICAL EXAMINATION: GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter. HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings. HEART: Regular rate and rhythm, without murmur. Normal S1, S2. LUNGS: Clear. No rales. No wheeze. Good excursion. ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly. EXTREMITIES: No edema, clubbing, or cyanosis. No rash. LABORATORY FINDINGS:  On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates. IMPRESSION: 1. Hypoglycemia due to not eating her meals on a regular basis. 2. Hypertension. 3. Renal insufficiency, may be dehydration, or diabetic nephropathy. PLAN:  Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.
CHIEF COMPLAINT:   Jaw pain this morning. BRIEF HISTORY OF PRESENT ILLNESS:   This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day. Also, history of chronic diverticulitis with recent bouts. The patient has been doing well, seen in my office at the end of December for complete physical examination. I had ordered a stress test for him, then delayed due to a family illness. However, denies any chest pain or chest tightness with exertion. The patient was doing well. He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand. He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain. He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event. The patient's pain resolved. He was given nitroglycerin in the emergency room drawing his blood pressure 67/32. Blood pressure quickly came back to normal with the patient's reverse Trendelenburg. FAMILY HISTORY:  Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink. PAST MEDICAL HISTORY:   Remarkable for tonsillectomies. MEDICATIONS:   Synthroid and Lipitor. ALLERGIES:   PENICILLIN AND BIAXIN. REVIEW OF SYSTEMS:   Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18. He is afebrile. GENERAL: He is well-developed, well-nourished white male, in no acute distress. HEENT: Pupils equal, round, and reactive to light and accommodation. Extraocular movements were intact. Throat was clear. NECK: Supple. There is no organomegaly or thyromegaly. Carotids are +2 without bruits. CHEST: Lungs are clear to auscultation and percussion. CV: Without any murmurs or gallops. ABDOMEN: Soft. There is no hepatosplenomegaly. Bowel sounds are active. No tenderness. EXTREMITIES: No cyanosis, clubbing, or edema. Peripheral pulses 2+. NEUROLOGICAL: Intact. Motor exam is 5/5. LABORATORY STUDIES:   EKG is within normal limits, good sinus rhythm. His axis is somewhat leftward. CBC and BMP were normal and cardiac enzymes were negative x1. IMPRESSION: 1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent. 2. Hypercholesterolemia. 3. Hypothyroidism. PLAN:  Lipitor and thyroid have been ordered. His chest pain unit protocol for the stress thallium that will be done in the morning. If test is negative, we will discharge home. If positive, we will consult Cardiology. The patient requests Dr. ABC.
CHIEF COMPLAINT:  This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair. PAST MEDICAL HISTORY:  Significant only for hemorrhoidectomy. He does have a history of depression and hypertension. MEDICATIONS:  His only medications are Ziac and Remeron. ALLERGIES:   No allergies. FAMILY HISTORY:  Negative for cancer. SOCIAL HISTORY:   He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions. PHYSICAL EXAMINATION: GENERAL: Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department. HEENT: No scleral icterus. NECK: No cervical, supraclavicular, or axillary adenopathy. LUNGS: Clear. HEART: Regular. No murmurs or gallops. ABDOMEN: As noted, obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus. DIAGNOSTIC STUDIES: Normal sinus rhythm on EKG, prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5, hematocrit was 48, and platelet count was 307. ASSESSMENT AND PLAN:   Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.
CHIEF COMPLAINT:  Nausea, vomiting, diarrhea, and fever. HISTORY OF PRESENT ILLNESS:  This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness. PAST MEDICAL HISTORY:  Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism. MEDICATIONS: Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone. SOCIAL HISTORY:  The patient has been residing at South Valley Care Center. REVIEW OF SYSTEMS:  The patient is unable answer review of systems. PHYSICAL EXAMINATION: GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress. HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full. NECK: Supple with full range of motion and no masses. LUNGS: There are decreased breath sounds at the bases bilaterally. CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4. ABDOMEN: Soft and nontender with no hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient moves all extremities but does not communicate. DIAGNOSTIC STUDIES:  The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3. IMPRESSION/PLAN: 1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration. 2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole. 3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium. 4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. ,
CHIEF COMPLAINT:   Fever. HISTORY OF PRESENT ILLNESS:   This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. Mother states he just completed Amoxil several days ago for a sinus infection. Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum. Mother states that his temperature usually elevates at night. Two days his temperature was 102.6. Mother has not taken it since, and in fact she states today he seems much better. He is cutting an eye tooth that causes him to be drooling and sometimes fussy. He has had no vomiting or diarrhea. There has been no coughing. Nose secretions are usually discolored in the morning, but clear throughout the rest of the day. Appetite is fine. PHYSICAL EXAMINATION: General: He is alert in no distress. Vital Signs: Afebrile. HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares patent. Clear secretions present. Oropharynx is clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular, no murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. Skin: Normal turgor. ASSESSMENT: 1. Allergic rhinitis. 2. Fever history. 3. Sinusitis resolved. 4. Teething. PLAN:   Mother has been advised to continue Zyrtec as directed daily. Supportive care as needed. Reassurance given and he is to return to the office as scheduled.
CHIEF COMPLAINT:   Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke. CURRENT MEDICATIONS:   Vioxx 25 mg daily, HCTZ 25 mg one-half tablet daily, Zoloft 100 mg daily, Zyrtec 10 mg daily. ALLERGIES TO MEDICATIONS:  Naprosyn. SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY AND SURGICAL HISTORY:  She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker. Please see notes dated 06/28/2004. REVIEW OF SYSTEMS:   Review of systems is otherwise negative. PHYSICAL EXAMINATION: Vital Signs: Age: 60. Weight: 192 pounds. Blood pressure: 134/80. Temperature: 97.8 degrees. General: A very pleasant 60-year-old white female in no acute distress. Alert, ambulatory and nonlethargic. HEENT: PERRLA. EOMs are intact. TMs are clear bilaterally. Throat is clear. Neck: Supple. No cervical adenopathy. Lungs: Clear without wheezes or rales. Heart: Regular rate and rhythm. Abdomen: Soft nontender to palpation. Extremities: Moving all extremities well. IMPRESSION: 1. Short-term memory loss, probable situational. 2. Anxiety stress issues. PLAN:   Thirty-minute face-to-face appointment in counseling with the patient. At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn. The current job she is at does sound extremely stressful and demanding. I think her stress reactions to these as far as feeling frustrated are within normal limits. We did complete a mini mental state exam including clock drawing, sentence writing, signature, etc. She does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation. I did spend quite a bit of time reassuring her as well. She is currently on Zoloft 100 mg which I think is an appropriate dose. We will have her continue on that. She did verbalize understanding and that she actually felt better after our discussion concerning these issues. At some point in time; however, I would possibly recommend job change if this one would persist as far as the stress levels. She is going to think about that.
CHIEF COMPLAINT:   Weak and shaky. HISTORY OF PRESENT ILLNESS:   The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further, she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough, hemoptysis, dyspnea, and wheeze. She denies syncope, presyncope, or palpitations. Her symptoms are fairly longstanding but have been worsening as of late. PAST MEDICAL HISTORY:   She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair. CURRENT MEDICATIONS:   She is on two different medications, neither of which she can remember the name and why she is taking it. ALLERGIES:  She has no known medical allergies. FAMILY HISTORY:   Remarkable for coronary artery disease, stroke, and congestive heart failure. SOCIAL HISTORY:   She is a widow, lives alone. Denies any tobacco or alcohol use. REVIEW OF SYSTEMS:   Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling. PHYSICAL EXAMINATION: General: She is alert but seems somewhat confused and is not able to provide specific details about her past history. Vital Signs: Blood pressure: 146/80. Pulse: 68. Weight: 147 pounds. HEENT: Unremarkable. Neck: Supple without JVD, adenopathy, or bruit. Chest: Clear to auscultation. Cardiovascular: Regular rate and rhythm. Abdomen: Soft. Extremities: No edema. LABORATORY:   O2 sat 100% at rest and with exertion. Electrocardiogram was normal sinus rhythm. Nonspecific S-T segment changes. Chest x-ray pending. ASSESSMENT/PLAN: 1. Dyspnea on exertion, uncertain etiology. Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors. We will have the patient sign a release of records so that we can review her previous history. Consider setting up for a stress test. 2. Hypertension, blood pressure is acceptable today. I am not certain as to what, if the patient’s is on any antihypertensive agents. We will need to have her call us what the names of her medications, so we can see exactly what she is taking. 3. History of diabetes. Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C. I have to obtain some further history and review records before proceeding with treatment recommendations.
CHIEF COMPLAINT: 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex. HISTORY OF PRESENT ILLNESS:   The patient is a 29-year-old female who is here today with the above-noted complaints. She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past. She is requesting antibiotics. She has been squeezing them and some of them are very bruised and irritated. She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again. She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all. She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off. She states she does not wish to be on any medication at the current time. She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she "wants to.",PAST MEDICAL HISTORY:   Significant for cleft palate. ALLERGIES:   She is allergic to Lortab. CURRENT MEDICATIONS:   None. REVIEW OF SYSTEMS:   Please see history of present illness. Psychiatric: She has had some suicidal thoughts, but no plans. She denies being suicidal at the current time. Cardiopulmonary: She has not had any chest pain or shortness of breath. GI: Denies any nausea or vomiting. Neurological: No numbness, weakness or tingling. PHYSICAL EXAMINATION: General: The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress. Vital signs: Weight: 160 pounds. Blood pressure: 100/60. Pulse: 62. Psychiatric: I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that. Extremities: Her inner thighs are covered with multiple areas of folliculitis and mild abscesses. They are bruised from her squeezing them. We talked about that in detail. ASSESSMENT: 1. Folliculitis. 2. Pelvic pain. 3. Mood swings. 4. Dyspareunia. PLAN: 1. I would like her to go to the lab and get a CBC, chem-12, TSH and UA. 2. We will put her on cephalexin 500 mg three times a day. 3. We will send her back to see Dr. XYZ regarding the pelvic pain per her request. 4. We will get her an appointment with a psychiatrist for evaluation and treatment. 5. She is to call if she has any further problems or concerns. Otherwise I will see her back for her routine care or sooner if there are any further issues.