falan42/nurse_detection huggingface dataset:
Speech Therapy - Discharge Summary 

LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: 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.,
Pyelonephritis - Discharge Summary 

ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.discharge summary, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit
Pancreatic Mass - Discharge Summary 

HISTORY OF PRESENT ILLNESS: ,  The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.  The patient, additionally, had a questionable pseudocyst in the tail of the pancreas.  The patient underwent ERCP on 04/04/2007 with placement of a stent.  This revealed a strictured pancreatic duct, as well as strictured bile duct.  A 10-french x 9 cm stent was placed with good drainage.  The next morning, the patient felt quite a bit more comfortable.  He additionally had a modest drop in his bilirubin and other liver tests.  Of note, the patient has been having quite a bit of nausea during his admission.  This responded to Zofran.  It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself.  At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000.  His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3.  His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8.  He was tolerating a regular diet.  The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale.  The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary.  He will be further managed for his diabetes there.  The patient will additionally undergo potential end of life meetings.  I discussed the potentials of chemotherapy with patient.  Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity.  The patient will consider this and will discuss this further with Dr. X.  ,DISCHARGE MEDICATIONS:,1.  Phenergan 25 mg q.6. p.r.n.,2.  Duragesic patch 100 mcg q.3.d.,3.  Benadryl 25-50 mg p.o. q.i.d. for pruritus.,4.  Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.,5.  The patient had initially been on enalapril here.  His hypertension will be managed by Dr. X as well.  ,PLAN: , The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain.  In the meantime, he will be kept on a regular diet and activity per Dr. X.discharge summary, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage,
ORIF - Discharge Summary 

ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.discharge summary, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,
Neurology - Discharge Summary 

PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.discharge summary, interhemispheric, frontal lobe, head injury, brain, contusion
Occupational Therapy Discharge Summary 

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions.  Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program.  Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.discharge summary, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,
Pneumonia - Discharge Summary 

ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.discharge summary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,
Post Thyroidectomy - Discharge Summary 

ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.discharge summary, nodular, symptomatic thyroid goiter, thyroidectomy, goiter,
Mullerian Adenosarcoma 

PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.discharge summary, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma
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.discharge summary, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis
Neonatal Discharge Summary 

HOSPITAL COURSE:,  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.  Baby was born at 5:57 on 07/30/2006.  Mother received ampicillin 2 g 4 hours prior to delivery.  Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate.  Baby was born with Apgar scores of 8 and 9 at delivery.  Fluid was cleared.  Nuchal cord x1.  Prenatal was at ABC Valley.  Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive.  Baby was suctioned on perineum with good support.  The baby was admitted to the NICU for prematurity and to rule out sepsis.  Baby's cry was good.  Color, tone, and __________ mild retractions.  CBC, CRP, blood cultures were done.  IV fluids of D10 at a rate of 6 mL an hour.  Ampicillin and gentamicin were started via protocol.  At the time of admission, the patient was stable on room air and has feeding issues.  Baby was fed EBM 22 and NeoSure per os.  Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours.  The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced.  Also, the baby was able to suck properly and was tolerating feeds.  The baby was fed EBM 22 and NeoSure was added a day before discharge.  At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:,  Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:,  Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006.  CPR teaching was completed on 08/11/2006 to parents.  Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed.  Ad lib feeding on demand.discharge summary, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge,
Neck Pain - Discharge Summary 

ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.discharge summary, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,
Kawasaki Disease - Discharge Summary 

ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:,  Kawasaki disease, resolving.,HOSPITAL COURSE:,  This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.  When he was sent to the hospital, he had a fever of 102.  Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG.  Echocardiogram was also done, which was negative.  IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever.  Today, his fever and his rash have completely resolved.  He does not have any conjunctivitis and no redness of mucous membranes.  He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:,  Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day.  He will be followed by his primary doctor in 2 to 3 days.  Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.discharge summary, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin