falan42/nurse_detection huggingface dataset:
Weight Loss on Phentermine 

SUBJECTIVE:,  She is here for a followup on her weight loss on phentermine.  She has gained another pound since she was here last.  We talked at length about the continued plateau she has had with her weight.  She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136.  She is frustrated with this as well.  We agree that if she continues to plateau she really should not stay on phentermine.  We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees.,REVIEW OF SYSTEMS:,  Otherwise negative.  She has no specific complaints.  No shortness of breath, chest pain or palpitations.,PHYSICAL EXAM:,Vital signs:  Her blood pressure is fine.  Her diastolic is a little bit high, but otherwise okay.,General:  She appears in good spirits.  No apparent distress.,HEENT:  Negative.,Neck:  Supple without bruits.,Chest:  Clear.,Cardiac exam:  Regular without extra sounds.,ASSESSMENT:,  Weight loss on phentermine, really has plateaued.,PLAN:,  If she does not lose weight in the next month we will probably consider having her go off the phentermine.  If she does lose a couple of pounds, then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop.  She agrees with this plan.soap / chart / progress notes, followup, phentermine, plateau, weight, weight loss, weight loss on phentermine, loss
Laryngitis - Discharge 

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.speech - language, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis
Barium Swallow Study & Speech Evaluation - 1 

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.speech - language, gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration
Wasp Sting - SOAP 

SUBJECTIVE:,  He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.  He says that he has been stung by wasps before and had similar reactions.  He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past.  He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,OBJECTIVE:,Vitals:  His temperature is 98.4.  Respiratory rate is 18.  Weight is 250 pounds.,Extremities:  Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow.  He says that it is really not painful or anything like that.  It is really not all that red and no signs of infection at this time.,ASSESSMENT:,  Wasp sting to the right wrist area.,PLAN:,1.  Solu-Medrol 125 mg IM X 1.,2.  Over-the-counter Benadryl, ice and elevation of that extremity.,3.  Follow up with Dr. XYZ if any further evaluation is needed.soap / chart / progress notes, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp,
Tethered Cord Evaluation 

REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.soap / chart / progress notes, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,
URI - SOAP 

SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.soap / chart / progress notes, soap, uri, upper respiratory infection, water's view, congestion, light reflex, sore throat, respiratory, strep, infection,
Total Abdominal Hysterectomy - Followup 

POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,soap / chart / progress notes, postoperative course, total abdominal hysterectomy, postoperative
Three-Week Postpartum Checkup 

CHIEF COMPLAINT:,  The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:,  She is doing well postpartum.  She has had no headache.  She is breastfeeding and feels like her milk is adequate.  She has not had much bleeding.  She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  She has not yet had sexual intercourse.  She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  She has not been particularly constipated but her husband says she is not eating her vegetables like she should.  Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:,  Prenatal vitamins.,ALLERGIES:,  She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy.  Dad is 40 and healthy.  Half-sister, age 34, is healthy.  She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS:  Weight:  124 pounds.  Blood pressure 96/54.  Pulse:  72.  Respirations:  16.  LMP:  10/18/03.  Age:  39.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen:  Soft.  No masses.,Pelvic:  Uterus is involuting.,Rectal:  She has one external hemorrhoid which has inflamed.  Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:,  Satisfactory three-week postpartum course, seasonal allergies.  We will try Patanol eyedrops and Allegra 60 mg twice a day.  She was cautioned about the possibility that this may alter her milk supply.  She is to drink extra fluids and call if she has problems with that.  We will try ProctoFoam HC.  For the hemorrhoids, also increase the fiber in her diet.  That prescription was written, as well as one for Allegra and Patanol.  She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  She will call and return if she continues to have problems with allergies.  Meantime, rechecking in three weeks for her final six-week postpartum checkup.soap / chart / progress notes, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,
Thrombocytosis Followup 

CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:nan
Thrombocytopenia - SOAP Note 

SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,soap / chart / progress notes, platelets, platelet count, thrombocytopenia, prednisone,
Urinary Frequency & Urgency - Followup 

HISTORY OF PRESENT ILLNESS:  ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence.  This has been progressively worsening, and previously on VESIcare with no improvement.  She continues to take Enablex 50 mg and has not noted any improvement of her symptoms.  The nursing home did not do a voiding diary.  She is accompanied by her power of attorney.  No dysuria, gross hematuria, fever or chills.  No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION:  ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.  This has not improved on VESIcare as well as Enablex.  Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure.  The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today.  Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided.  They will see Dr. X with a prior voiding diary, which is again discussed.  All questions answered.,PLAN:,  As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney.  In the meantime, Sanctura prescription is provided, and voiding diaries are provided.  All questions answered.soap / chart / progress notes, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding
Urinary Retention - Followup 

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup.  No dysuria, gross hematuria, fever, chills.  She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence.  She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0.  No incontinence.  No straining to urinate.  Good stream, emptying well.  No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION:  ,1.  The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2.  Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily.  She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention.  All questions answered.soap / chart / progress notes, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence,
SOAP - Shortness of Breath 

SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,