falan42/nurse_detection huggingface dataset:
Detox from Heroin 

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.consult - history and phy., phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse,
Dietary Consult - 1 

SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.consult - history and phy., vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol
Consult - Prostate Cancer 

CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer.  The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence.  These were discussed at length.  Alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the HDR radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also.  There is a risk of rectal fistula.  Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency.  Potency may not recover after the hormone therapy has been completed.  Cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency.  There is a risk of rectal fistula.  He would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately.  Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence.  Observation therapy was discussed with him in addition.  I answered all questions that were put to me and I think he understands the options that are available.  I spoke with the patient for over 60 minutes concerning these options.consult - history and phy., prostate cancer, cryosurgery, hdr radiation, prostate surgery, bladder, bleeding, bowel, consultation, impotence, incontinence, infection, prostatectomy, radiation therapy, radical, rectal, rectal fistula, rectal injury, prostate cancer consult, cancer, radiation, prostateNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,
Consult - Smoking Cessation  

CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.consult - history and phy., quit smoking, chantix, mesothelioma, smoking, xanax, refills
Consult - Screening Colonoscopy 

HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.consult - history and phy., screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy,
Consult - Hydronephrosis 

CHIEF COMPLAINT:,  Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma.  She is scheduled to undergo mastectomy in two weeks.  In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation.  Again, she is scheduled for mastectomy in two weeks.  She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney.  There was no dilation of the right ureter noted.  Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:,  Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:,  None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  She is retired.  Does not smoke or drink.,REVIEW OF SYSTEMS:,  I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:,  Please see the physical exam sheet I completed.  Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria.  She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005.  I will try to obtain the report to see if the right kidney was evaluated at that time.  She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney.  She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed.  She will call us back to schedule the x-rays.  She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer.  There is also a question of a stone present in the kidney.  She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.consult - history and phy., hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer,
Consult - Laparoscopic Cholecystectomy  

PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed.  She is married.  She is in sales.  She does not smoke.  She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec.  She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:,  Negative for heart, lungs, GI, GU, cardiac, or neurologic.  Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile.  Vital Signs are stable.  HEENT:  EOMI.  PERRLA.  Neck is soft and supple.  Lungs clear to auscultation.  She is mildly tender in the abdomen in the right upper quadrant.  No rebound.  Abdomen is otherwise soft.  Positive bowel sounds.  Extremities are nonedematous.  Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications.  She understands and we will proceed with the surgery in the near future.,consult - history and phy., laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal
Consult - Hypertension 

HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.consult - history and phy., hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, renal,
Consult - Back & Leg Pain 

Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,consult - history and phy., multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar
Consult - Cerebral Peduncle Infarction 

FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.consult - history and phy., internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle,