harishnair04/mtsamples huggingface dataset:
Circumcision Followup 
Medical specialty:  SOAP / Chart / Progress Notes
 Followup circumcision.  The patient had a pretty significant phimosis and his operative course was smooth.  Satisfactory course after circumcision for severe phimosis with no perioperative complications.

REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital.  The patient had a pretty significant phimosis and his operative course was smooth.  He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION:  ,Today, The patient looks healthy and happy.  We examined his circumcision site.  His Monocryl sutures are still in place.  The healing is excellent, and there is only a mild amount of residual postoperative swelling.  There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN:  ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  If that does occur, we will be happy to see him back at any time.,
Chronic Kidney Disease Followup 
Medical specialty:  SOAP / Chart / Progress Notes
 Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  Hypertension, which is finally better controlled.  Metabolic bone disease and anemia.

HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease.  His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him.  I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes.  On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control.  He has also brought a machine at home, and states his blood pressure readings have been better.  He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past.  He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative.  He continues to feel well.  He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1.  Vytorin 10/40 mg one a day.,2.  Rocaltrol 0.25 micrograms a day.,3.  Carvedilol 12.5 mg twice a day.,4.  Cozaar 50 mg twice a day.,5.  Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings.  GENERAL:  He is a thin African American gentleman in no distress.  LUNGS:  Clear.  CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1 and S2.  I did not appreciate a murmur.  ABDOMEN:  Soft.  He has a very soft systolic murmur at the left lower sternal border.  No rubs or gallops.  EXTREMITIES:  No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9.  He is not on EPO yet.  His UA has been negative.,IMPRESSION:,1.  Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  His estimated GFR is 16 mL per minute.  He has no uremic symptoms.,2.  Hypertension, which is finally better controlled.,3.  Metabolic bone disease.,4.  Anemia.,RECOMMENDATION:,  He needs a number of things done in terms of followup and education.  I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes.  I also gave him websites that he can get on to find out more information.  I have not made any changes in his medications.  He is getting blood work done prior to his next visit with me.  I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05.  He will see me back in about 4 to 6 weeks.
Chest Pain & Respiratory Insufficiency 
Medical specialty:  SOAP / Chart / Progress Notes
 A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina.

We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.
Cataract Extraction Followup 
Medical specialty:  SOAP / Chart / Progress Notes
 Patient  follows up for cataract extraction with lens implant 2 weeks ago.   Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.

Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.
Care Conference With Family 
Medical specialty:  SOAP / Chart / Progress Notes
 Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.

REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.
Bunions and Calluses  
Medical specialty:  SOAP / Chart / Progress Notes
 A 60-year-old female presents today for care of painful calluses and benign lesions.

S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  She states that they do not hurt.  No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  This is a central plug.  She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1.  Bilateral bunions.,
Cardiology Progress Note 
Medical specialty:  SOAP / Chart / Progress Notes
 Problem of essential hypertension.  Symptoms that suggested intracranial pathology.

SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.
CAD - 6-Month Followup 
Medical specialty:  SOAP / Chart / Progress Notes
 He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.  He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.

REASON FOR VISIT:,  Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee.  He is also having trouble getting his nerves under control.  He is having stomach pains and occasional nausea.  His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.,MEDICATIONS:,  Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:,  BP:  140/78.  HR:  65.  WT:  260 pounds (which is up one pound).  There is no JVD.  No carotid bruit.  Cardiac:  Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  Lungs:  Clear.  Abdomen:  Mildly tender throughout the epigastrium.,Extremities:  No edema.,EKG:,  Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD):  Normal systolic and diastolic function.  Moderate LVH.  Possible gallstones seen.,IMPRESSION:,1.  CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD.  He has a stent in his LAD and his obtuse marginal.  Fairly stable.,2.  Dyspnea-Seems to be due to his weight and the disability from his knee.  His echocardiogram shows no systolic or diastolic function.,3.  Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4.  Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5.  Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6.  Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7.  Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1.  Discontinue Plavix.,2.  Aspirin reduced to 81 mg a day.,3.  Lorcet and Xanax prescriptions given.,4.  Refer over to Scotland Orthopedics.,5.  Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.
Cardiology Progress Note - 1 
Medical specialty:  SOAP / Chart / Progress Notes
  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.

SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.
Carbohydrate Counting 
Medical specialty:  SOAP / Chart / Progress Notes
 Dietary consultation for carbohydrate counting for type I diabetes.

SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.
Cataract - Second Opinion 
Medical specialty:  SOAP / Chart / Progress Notes
 The patient seeks evaluation for a second opinion concerning cataract extraction.  

SUBJECTIVE:  ,The patient seeks evaluation for a second opinion concerning cataract extraction.  She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery.  Past ocular surgery history is significant for neurovascular age-related macular degeneration.  She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU.  Manifest refraction does not improve this.  There is no afferent pupillary defect.  Visual fields are grossly full to hand motions.  Intraocular pressure measures 17 mm in each eye.  Slit-lamp examination is significant for clear corneas OU.  There is early nuclear sclerosis in both eyes.  There is a sheet like 1-2+ posterior subcapsular cataract on the left.  Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN:  ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting.  Cataracts are present in both eyes.  I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained.  This information was conveyed with the use of a translator.,