falan42/nurse_detection huggingface dataset:
Foot Pain - SOAP 

SUBJECTIVE:,  This 32-year-old female comes in again still having not got a primary care physician.  She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect.  She says that Project Access is trying to find her a doctor.  She is not currently on Project Access, and so she is here to get something for the pain in her foot.  I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004.  She said she does not have a primary care physician.  She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers.  She has been in here multiple times for different kinds of pain.  This pain she is having is in her foot.  She had surgery on it, and she has plates and screws.  She said she was suppose to see Dr. XYZ about getting some of the hardware out of it.  The appointment was cancelled, and that is why she came here.  It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her.  She did not injure her foot in any way recently.  It is chronically painful.  Every time she does very much exercise it hurts more.  We have x-rayed it in the past.  She has some hardware there.  It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars.  On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  They are all old, and the surgery was done over a year ago.  She is walking with a very slight limp.  There is no redness.  No heat.  No swelling of the foot or the ankle.  It is mildly tender around the medial side of the foot just inferior to the medial malleolus.  It is not warm or red.,ASSESSMENT:,  Foot pain.,PLAN:,  She has been in here before.  She seems very pleasant.  Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill.  After she left, I got to thinking about it and looked into her record.  She has been in here multiple times for pain medicine.  She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago.  We called Dr. XYZ office.  Dr. XYZ nurse said that the patient did not have an appointment today.  She has an appointment on June 15, 2004, for a postop check.  They did not tell her they would not see her today because of insurance, so the patient was lying to me.  We will keep that in mind the next time she returns, because she will likely be back.  She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.soap / chart / progress notes, soap, foot pain, primary care physician, project access, insurance, foot, project, access, care, appointment
Gen Med Progress Note 

SUBJECTIVE:,  The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL:  The patient looks tired.,HEENT:  Oral mucosa is dry.,CHEST:  Clear to auscultation.  He states that he has a mild cough, not productive.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES:  There is no swelling.,NEURO:  The patient is alert and oriented x 3.  Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  Glucose is in the low 100s.  Comprehensive metabolic panel is unremarkable.  UA is negative for infection.,ASSESSMENT AND PLAN:,1.  Fever of undetermined origin, probably viral since white count is normal.  Would continue current antibiotics empirically.,2.  Dehydration.  Hydrate the patient.,3.  Prostatic hypertrophy.  Urologist, Dr. X.,4.  DVT prophylaxis with subcutaneous heparin.soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,
Fundoplication & Gastrostomy Followup 

REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.soap / chart / progress notes, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication,
Foreskin - Followup 

REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well.  He has a relatively unremarkable foreskin.  At this point in time, he otherwise seems to be doing reasonably well.  The question is about the foreskin.  He otherwise has no other significant issues.  Severity low, ongoing since birth two weeks.  Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:,  Male exam.  Normal and under the penis, report normal uncircumcised 2-week-old.  He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe.  I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision.  This kid should otherwise do reasonably well.,PLAN:  ,Follow up as needed.  But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin,
Evaluation of Allergies 

HISTORY:,  A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies.  Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION:  ,1.  Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2.  History of fibromyalgia.,3.  History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4.  History of chronic fatigue.,5.  History of hypothyroidism.,6.  History of depression.,7.  History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation.  The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested.  The patient will follow up after RAST allergy testing for further treatment recommendations.  At this point, no changes in her medication were prescribed until her followup visit.soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy
Fifth Disease - SOAP 

SUBJECTIVE:,  Grandfather brings the patient in today because of headaches, mostly in her face.  She is feeling pressure there with a lot of sniffles.  Last night, she complained of sore throat and a loose cough.  Over the last three days, she has had a rash on her face, back and arms.  A lot of fifth disease at school.  She says it itches and they have been doing some Benadryl for this.  She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:,  Asthma and allergies.,FAMILY HISTORY:  ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General:  The patient is an 11-year-old female.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color and good light reflex.  Oropharynx is pink and moist.  No erythema or exudates.  She has postnasal discharge.  Nares are swollen and red.  Purulent discharge in the posterior turbinates.  Both maxillary sinuses are tender.  She has some mild tenderness in the left frontal sinus.  Eyes are puffy and she has dark circles.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink.  Moist mucous membranes.  Red, lacey rash from the wrists to the elbows, both sides.  It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:,  Fifth disease with sinusitis.,PLAN:,  Omnicef 300 mg daily for 10 days.  May use some Zyrtec for the itching.  Samples are given.soap / chart / progress notes, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx,
Gastric Bypass - Preop Eval 

REASON FOR VISIT:,  Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3.  Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds.  Abdomen:  Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:,  The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks.  Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection.  Questions regarding hospital course and recovery were addressed.  We will continue on the Medifast diet until the time of surgery and cleared for surgery.soap / chart / progress notes, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,
Foot Lesions 

S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes.  She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  The first and fifth metatarsal heads are plantarflexed.  Vibratory sensation appears to be absent.  Dorsal pedal pulses are nonpalpable.  Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  The medial aspect of the left great toenail has dried blood under the nail.  The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  All of the patient's toenails are elongated and discolored and opaque as well.  There is dried blood under the medial aspect of the left great toenail.,A - ,1.  Painful feet.,soap / chart / progress notes, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful
Facial Rhytids 

HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids.  In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues.  I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.soap / chart / progress notes, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: 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.,
Followup Screw Fixation 

REASON FOR VISIT:  ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  He is currently at home and has left nursing home facility.  He states that his pain is well controlled.  He has been working with physical therapy two to three times a week.  He has had no drainage or fever.  He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed.  He has no effusion noted.  His range of motion is 10 to 105 degrees.  He has no pain or crepitance.  On examination of his right foot, he is nontender to palpation of the metatarsal heads.  He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.  He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  These appear to be extraarticular.  They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT:  ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy.  He may be weightbearing as tolerated on his right side.  I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias.  He said he has had the left thigh for a number of years and has been followed by a neurologist for this.  He states that he has had some right-sided paresthesias now for a number of weeks.  He claims he has no other symptoms of any worsening stenosis.  I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.soap / chart / progress notes, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal
E. Coli UTI - Followup 

HISTORY OF PRESENT ILLNESS:,  The patient presents today for followup, recently noted for E. coli urinary tract infection.  She was treated with Macrobid for 7 days, and only took one nighttime prophylaxis.  She discontinued this medication to due to skin rash as well as hives.  Since then, this had resolved.  Does not have any dysuria, gross hematuria, fever, chills.  Daytime frequency every two to three hours, nocturia times one, no incontinence, improving stress urinary incontinence after Prometheus pelvic rehabilitation.,Renal ultrasound, August 5, 2008, reviewed, no evidence of hydronephrosis, bladder mass or stone.  Discussed.,Previous urine cultures have shown E. coli, November 2007, May 7, 2008 and July 7, 2008.,CATHETERIZED URINE: , Discussed, agreeable done using standard procedure.  A total of 30 mL obtained.,IMPRESSION: , Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection, completed the therapeutic dose, but stopped the prophylactic Macrodantin due to hives.  This has resolved.,PLAN: , We will send the urine for culture and sensitivity, if no infection, patient will call results on Monday, and she will be placed on Keflex nighttime prophylaxis, otherwise followup as previously scheduled for a diagnostic cystoscopy with Dr. X.  All questions answered.soap / chart / progress notes, urinary tract infection, escherichia coli, prophylactic macrodantin, e. coli, infection,
Endometrial Cancer Followup 

CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:soap / chart / progress notes, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,
Erectile Dysfunction - Followup 

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg.  He indicates that he has noticed some mild improvement of his symptoms, with no side effect.  On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes.  No chest pain, no nitroglycerin usage, no fever, no chills.  No dysuria, gross hematuria, fever, chills.  Daytime frequency every three hours, nocturia times 0, good stream.  He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate.  PSA 11.6.  Dr. X's notes are reviewed.,IMPRESSION:  ,1.  Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time.  We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2.  Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate.  The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy.  However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed.  The patient not to use them at the same time.  Will call if any other concern.  In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy.  He declined scheduling this at this time.  All questions answered.soap / chart / progress notes, improvement of erectile dysfunction, erectile dysfunction, erectile, dysfunction, cialis, psa, biopsy,