harishnair04/mtsamples huggingface dataset:
Consult/ER Report - OB/GYN 
Medical specialty:  Emergency Room Reports
 A female with unknown gestational age who presents to the ED after a suicide attempt.

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
Chest Tube Insertion in ER 
Medical specialty:  Emergency Room Reports
 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.
Closed Head Injury 
Medical specialty:  Emergency Room Reports
 Status post a high-speed motor vehicle accident in which patient was ejected from the vehicle.

CHIEF COMPLAINT:,  Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle.  He denies loss of consciousness, although the EMT people report that he did have loss of consciousness.  The patient was stable en route.  Upon arrival, he complained of headache.,PAST MEDICAL HISTORY:,  Medical:  None.  Surgical:  None.,REVIEW OF SYSTEMS: , CARDIAC:  No history.  PULMONARY:  Some morning cough.  (Patient is a smoker.),MEDICATIONS:,  None.,ALLERGIES:,  ALLERGIC TO PENICILLIN, CAUSES SKIN RASH.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°.,HEENT:  Contusion over right occipital area.  Tympanic membranes benign.,NECK:  Nontender.,CHEST:  Atraumatic, nontender.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Flat, soft, and nontender.,BACK:  Atraumatic, nontender.,PELVIS:  Stable,EXTREMITIES:  Contusion over right forearm.  No bone deformity or crepitus.,RECTAL:  Normal sphincter tone; guaiac negative.,NEUROLOGIC:  Glasgow coma scale 15.  Pupils equal, round, reactive to light.  Patient moves all 4 extremities without focal deficit.,LABORATORY DATA: , Serial hematocrits 42.4, and 40.4.  White blood count 6.3.  Ethanol:  None.  Amylase 66.  Urinalysis normal.  PT 12.6, PTT 29.  Chem-7 panel within normal limits.,X-rays of cervical spine and lumbosacral spine within normal limits.  X-rays of pelvis and chest within normal limits.,ASSESSMENT:,1.  Closed head injury.,2.  Rule out intra-abdominal injury.,PLAN:,  The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.
Asthma in a 5-year-old 
Medical specialty:  Emergency Room Reports
 Mother states he has been wheezing and coughing.

CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma."  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.
Ankle pain 
Medical specialty:  Emergency Room Reports
 Acute foot or ankle sprain, possible small fracture.

CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:
Airway Compromise & Foreign Body - ER Visit 
Medical specialty:  Emergency Room Reports
 The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.

HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.
Ant Bait Exposure - ER Visit 
Medical specialty:  Emergency Room Reports
 Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.
Air Under Diaphragm - Consult 
Medical specialty:  Emergency Room Reports
 Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology.

REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.
Speech Therapy - Discharge Summary - 2 
Medical specialty:  Discharge Summary
 The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke.  The patient attended nine outpatient skilled speech therapy sessions.

The patient made some progress during therapy.  She accomplished two and a half out of her five short-term therapy goals.  We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  Her last session occurred on 01/09/09.  She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.
Accidental Celesta Ingestion - ER Visit 
Medical specialty:  Emergency Room Reports
 Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.

HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills "didn't taste good," so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.
TAH - Discharge Summary 
Medical specialty:  Discharge Summary
 Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.  

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.