falan42/nurse_detection huggingface dataset:
Multiple Medical Problems 

SUBJECTIVE:,  The patient was seen today by me at Nursing Home for her multiple medical problems.  The nurses report that she has been confused at times, having incontinent stool in the sink one time but generally she does not do that poorly.  She does have trouble walking which she attributes to weak legs.  She fell a couple of months ago.  Her eating has been fair.  She has been losing weight a little bit.  She denies diarrhea.  She does complain of feeling listless and unambitious and would like to try some Ensure.,CURRENT MEDICATIONS:,  Her meds are fairly extensive and include B12 1000 mg IM monthly, Digitek 250 p.o. every other day alternating with 125 mcg p.o. every other day, aspirin 81 mg daily, Theragran-M daily, Toprol XL 25 mg daily, vitamin B6 100 mg daily, Prevacid 30 mg daily, Oyster Shell calcium with D 500 mg t.i.d., Aricept 5 mg daily, Tylenol 650 mg q.4h. p.r.n., furosemide 20 mg daily p.r.n., and sublingual Nitro p.r.n., and alprazolam 0.25 mg p.r.n.,ALLERGIES:,  Sulfa and trimethoprim.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 90.  Temperature is 98.5 degrees.  Blood pressure:  100/54.  Pulse:  60.  Respirations:  18.  Weight was 132.6 about a week ago, which is down one pound from couple of months ago.,HEENT:  Head was normocephalic.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  No calf tenderness or significant ankle edema x 2 in the lower extremities is noted.,Mental Status Exam:  She was uncertain what season we are in.  She thought we were almost in winter.  She did know that today of the week was Friday.  She seemed to recognize me.,ASSESSMENT:,1.  Alzheimer’s dementia.,2.  Gradual weight loss.,3.  Fatigue.,4.  B12 deficiency.,5.  Osteoporosis.,6.  Hypertension.,PLAN:,  I ordered yearly digoxin levels.  Increased her Aricept to 10 mg daily.  She apparently does have intermittent atrial fibrillation as a reason for being on the digoxin.  We will plan to recheck her in a couple of months.  Ordered health supplement to be offered after each meal due to her weight loss.soap / chart / progress notes, progress note, alzheimer’s dementia, b12 deficiency, fatigue, hypertension, osteoporosis, digoxin, incontinent stool, multiple medical problems, weak, weight loss, multiple, dementia, alzheimer’s, incontinent,
Non-Hodgkin lymphoma Followup 

CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:nan
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.soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE
Lung Cancer Followup 

CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:soap / chart / progress notes, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer,
Lap Band Adjustment 

REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,soap / chart / progress notes, lap band adjustment, lap band placement, lap band,
Lobectomy - Followup 

HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.soap / chart / progress notes, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer
Infected Toenails 

S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,
Hypertension - Progress Note 

SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.soap / chart / progress notes, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea,
Gen Med SOAP - 8 

SUBJECTIVE: , I am following the patient today for multiple issues.  He once again developed gross hematuria, which was unprovoked.  His Coumadin has been held.  The patient has known BPH and is on Flomax.  He is being treated with Coumadin because of atrial fibrillation and stroke.  This is the second time he has had significant gross hematuria this month.  He also fell about a week ago and is complaining of buttock pain and leg pain.  We did get x-rays of hips, knees, and ankles.  Clearly, he has significant degenerative disease in all these areas.  No fractures noted however.  He felt that the pain is pretty severe and particularly worse in the morning.  His sinuses are bothering him.  He wonders about getting some nasal saline spray.  We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  He is not in any apparent distress.  He is comfortable in a seated position.  I did not examine him further today.,ASSESSMENT AND PLAN:,1.  Hematuria.  Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH.  We will also obtain a repeat UA as he did describe to me some dysuria.  However, I do not think this would account for the gross hematuria.  He will be started on an aspirin 81 mg p.o. daily.,2.  For the pain we will try him on Lortab.  He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3.  We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4.  For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use.soap / chart / progress notes, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria,
HIV Followup 

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease.  His last CD4 count was 425, viral load was less than 50 in 08/07.  He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus.  He also has a history of hypertension and hypertriglyceridemia.  He had been having increased urination and thirst.  He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess.  The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide.  The patient reports that he has been taking the medication.  He is in general feeling better.  He says that his gluteal abscess is improving and he will be following up with Surgery today.,CURRENT MEDICATIONS:,1.  Gabapentin 600 mg at night.,2.  Metformin 1000 mg twice a day.,3.  Glipizide 5 mg a day.,4.  Flagyl 500 mg four times a day.,5.  Flexeril 10 mg twice a day.,6.  Paroxetine 20 mg a day.,7.  Atripla one at night.,8.  Clonazepam 1 mg twice a day.,9.  Blood pressure medicine, name unknown.,REVIEW OF SYSTEMS:,  He otherwise has a negative review of systems.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.)  HEENT:  Unremarkable except for some submandibular lymph nodes.  His fundi are benign.  NECK:  Supple.  LUNGS:  Clear to auscultation and percussion.  CARDIAC:  Reveals regular rate and rhythm without murmur, rub or gallop.  ABDOMEN:  Soft and nontender without organomegaly or mass.  EXTREMITIES:  Show no cyanosis, clubbing or edema.  GU:  Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,IMPRESSION:,1.  Human immunodeficiency virus disease with stable control on Atripla.,2.  Resolving left gluteal abscess, completing Flagyl.,3.  Diabetes mellitus, currently on oral therapy.,4.  Hypertension.,5.  Depression.,6.  Chronic musculoskeletal pain of unclear etiology.,PLAN: , The patient will continue his current medications.  He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter.  He has been encouraged to keep his appointment with his psychologist.soap / chart / progress notes, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension,
Gen Med SOAP - 6 

SUBJECTIVE:,  The patient is in with several medical problems.  He complains his mouth being sore since last week and also some "trouble with my eyes."  He states that they feel "funny" but he is seeing okay.  He denies any more diarrhea or abdominal pain.  Bowels are working okay.  He denies nausea or diarrhea.  Eating is okay.  He is emptying his bladder okay.  He denies dysuria.  His back is hurting worse.  He complains of right shoulder pain and neck pain over the last week but denies any injury.  He reports that his cough is about the same.,CURRENT MEDICATIONS:,  Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General:  He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs:  His age is 66.  Temperature:  97.7.  Blood pressure:  134/80.  Pulse:  88.  Weight:  201 pounds.,HEENT:  Head was normocephalic.  Examination of the throat reveals it to be clear.  He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder.  Back has limited range of motion.  He is nontender to his back.  Deep tendon reflexes are 2+ bilaterally in lower extremities.  Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.  He has normal bowel sounds.,ASSESSMENT:,1.  Clostridium difficile enteritis, improved.,2.  Right shoulder pain.,3.  Chronic low back pain.,4.  Yeast thrush.,5.  Coronary artery disease.,6.  Urinary retention, which is doing better.,PLAN:,  I put him on Diflucan 200 mg daily for seven days.  We will have him stop his metronidazole little earlier at his request.  He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course.  I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.)  Recheck with me in two to three weeks.soap / chart / progress notes, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck,
Gen Med SOAP - 11 

SUBJECTIVE:,  The patient has recently had an admission for pneumonia with positive blood count.  She was treated with IV antibiotics and p.o. antibiotics; she improved on that.  She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102.  She was found to have strep.  She was treated with penicillin and sent home.  She returned about 8 o'clock after vomiting and a probable seizure.  Temperature was 104.5; she was lethargic after that.  She had an LP, which was unremarkable.  She had blood cultures, which have not grown anything.  The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:,  She is alert, recovering from anesthesia.  Head, eyes, ears, nose and throat are unremarkable.  Chest is clear to auscultation and percussion.  Abdomen is soft.  Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift.  CSF glucose was 68, protein was 16, and there were no cells.  The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count.  I am going to observe her overnight.soap / chart / progress notes, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure,