falan42/nurse_detection huggingface dataset:
Neurologic Examination 

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.consult - history and phy., station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE
Neurologic Consultation - 1 

SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.consult - history and phy., neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,
Neurogenic Bladder - Consult 

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day.  However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis.  He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria.  He was treated on IV antibiotics, Dr. XYZ also saw the patient.  Discharged home.  Not taking any antibiotics.  Today in the office, the patient denies any dysuria, gross hematuria, fever, chills.  He is catheterizing 3 times a day, changing his catheter weekly.  Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids.  Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space.  Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X.  No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION:  ,1.  Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2.  Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system.  He is asymptomatic today.  No complaints today.,PLAN:,  Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above.  Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so.  He will call if any concerns.  Follow up as previously scheduled in September for re-assessment.  All questions answered.  The patient is seen and evaluated by myself.consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,
Nephrology Consultation - 4 

HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.consult - history and phy., mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency,
Nephrology Consultation - 3 

PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol.  He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  His past surgical history is only significant for left AV fistula on the wrist done in 04/2008.  He still has urine output.  He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker.  He denies any alcohol.  No illicit drugs.  He used to work as the custodian at the nursing home, but now on disability since 03/2008.  He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:,  No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  His father is 67 years old, currently alive with asthma.  He also has one sister who has hypertension.  The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma.  No history of chest pain normal MI.  He has hypertension.  He occasionally will develop colds especially with weather changes.  GI:  Negative.  GU:  Still making urine about 1-3 times per day.  Musculoskeletal:  Negative.  Skin:  He complains of dry skin.  Neurologic:  Negative.  Psychiatry:  Negative.  Endocrine:  Negative.  Hematology:  Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds.  HEENT:  Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  Chest:  Equal chest expansion.  Clear breath sounds.  Heart:  Distinct heart sounds, regular rhythm with no murmur.  Abdomen:  Soft, nontender, flabby, no organomegaly.  Extremities:  Poor peripheral pulses.  No cyanosis and no edema.,ASSESSMENT AND PLAN:,  This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension.  He is on hemodialysis since 02/2008.  Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient.  Please feel free to contact me if there are any questions regarding his case.consult - history and phy., kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension
Microhematuria - Consult 

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He was seen a few weeks ago for routine followup, and he was noted for microhematuria.  Due to his history of kidney stone, renal ultrasound as well as IVP was done.  He presents today for followup.  He denies any dysuria, gross hematuria or flank pain issues.  Last stone episode was over a year ago.  No history of smoking.  Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  The calcification previously noted on the ureter appears to be outside the course of the ureter.  Otherwise unremarkable.  This is discussed.,IMPRESSION:  ,1.  A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.  The patient is asymptomatic.  We have discussed surgical intervention versus observation.  He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  Urine sent for culture and sensitivity.,PLAN: , As above.  The patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  Call if any concern.  The patient is seen and evaluated by myself.consult - history and phy., intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound
Multiple Meningiomas 

CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and "complete resection" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.consult - history and phy., sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: 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.
Meningioma 

CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.,EXAM: ,Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD, but no increase on upgaze OS. Optic disk pallor was evident OD, but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters.,IMPRESSION ON 2/6/89: ,Optic neuropathy/atrophy OD, rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus.,BRAIN CT W/CONTRAST, 2/13/89:, Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma.,MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST, 4/26/89:, 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma.,MRI 1995:, Mild enlargement of tumor with possible slight extension into the right cavernous sinus.,COURSE: ,Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection.consult - history and phy., goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma,
Mental Status Changes - Consult 

CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's.  Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes.  She was very confused, incomprehensible speech, and was not responding appropriately.  She was transported here stable, with no significant changes.  She ultimately upon arrival here was unchanged in that she was not responding appropriately.  She would have garbled speech, somewhat inappropriate at times, and unable to follow commands.  No other history was able to be obtained.  All pertinent history is documented within the records.  Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT:  Without any obvious signs of trauma.  Pupils are equal and reactive.  Extraocular movements are difficult to assess with her eyes closed, but she will open to voice.  TMs, canals are normal without any signs of hemotympanum.  Nasal mucosa and oropharynx are normal.,NECK:  Nontender, full range of motion, was not examined initially, a collar was placed.,HEART:  Regular.,LUNGS:  Clear.,CHEST/BACK/ABDOMEN:  Without trauma.,SKIN:  With multiple excoriations from scratching and itching.,NEUROLOGIC:  Otherwise she has good sensation, withdrawals to pain.  When lifting the arm, she will hold them up and draw, let them down slowly.  With movement of the legs, she did straighten them back out slowly.  DTRs were intact and equal bilaterally.  Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine.  She has a history of being on Coumadin.  Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands.  CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved.  It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved.  At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation.  I have discussed this with her son, he agrees.  Otherwise, she has improved significantly.  The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.consult - history and phy., alzheimer's, no loss consciousness, mental status,
MCA Aneurysm 

HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.consult - history and phy., mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral,