harishnair04/mtsamples huggingface dataset:
Rheumatoid Arthritis - Consult 
Medical specialty:  Consult - History and Phy.
 A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She is not on DMARD, but as she recently had a surgery followed by a probable infection.

HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She was followed by another rheumatologist.  She says she has been off and on, on prednisone and Arava.  The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone.  She says she had been on prednisone for the last 6 to 9 months.  She is on 5 mg a day.  She recently had a left BKA and there was a question of infection, so it had to be debrided.  I was consulted to see if her prednisone is to be continued.  The patient denies any joint pains at the present time.  She says when this started she had significant joint pains and was unable to walk.  She had pain in the hands and feet.  Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS:  BP 130/70, heart rate 80, and respiratory rate 14.,HEENT:  EOMI.  PERRLA.,NECK:  Supple.  No JVD.  No lymphadenopathy.,CHEST:  Clear to auscultation.,HEART:  S1 and S2.  No S3, no murmurs.,ABDOMEN:  Soft and nontender.  No organomegaly.,EXTREMITIES:  No edema.,NEUROLOGIC:  Deferred.,ARTICULAR:  She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:,  Labs in chart was reviewed.,ASSESSMENT AND PLAN:,  A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone.  She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that.  As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow.  If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone.  I would defer that to Dr. X.  If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone.  I discussed this at length with the patient and she is in full agreement with the plan.  I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.
Renal Insufficiency - Consult 
Medical specialty:  Consult - History and Phy.
 Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.

REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.
Recurrent Abscesses - Consult 
Medical specialty:  Consult - History and Phy.
 Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.   In the past, Accutane has been used.

REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:,  A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas.  She would usually have pustular type of lesion that would eventually break and would be quite painful.  The drainage would be malodorous.  It would initially not be infected as far as she knows, but then could eventually become infected.  She stated that this first started after she had her first born about 2 years ago.  She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months.  She was treated with multiple courses of antibiotics.  She had biopsies done.  She was seen by Dr. X.  Reportedly, she had a HIV test done that was negative.  She had been seen by a dermatologist who said that she had a problem with her sweat glands.  She has been on multiple courses of antibiotics.  She never had any fevers.  She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.,PAST MEDICAL HISTORY:,1.  History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years.  Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa.  Probably, she has had Staphylococcus infection associated with it as well.,2.  Reported history of asthma.,GYNECOLOGIC HISTORY: , G3, P1.  She is currently 5 months' pregnant.,ALLERGIES: , None.,MEDICATIONS: , Her medication had been Augmentin.,SOCIAL HISTORY: , She is followed by a gynecologist in Bartow.  She is not an alcohol or tobacco user.  She is not married.  She has a 2-year-old child.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.,PHYSICAL EXAMINATION,GENERAL:
Rectal Bleeding - Consult 
Medical specialty:  Consult - History and Phy.
 A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  

REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.
Pulmonary Consultation - 1 
Medical specialty:  Consult - History and Phy.
 Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study.

CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.
Pubic Cellulitis 
Medical specialty:  Consult - History and Phy.
 A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.

DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:,  A 16-month-old with history of penile swelling for 4 days.  The patient was transferred for higher level of care.  This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent.  Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions.  This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area.  The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics.  The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT:  Denies any runny nose.  ,EYES:  No apparent discharge.  ,FEEDING:  Good feeding.  ,CARDIOVASCULAR:  There is no cyanosis or edema.  ,RESPIRATORY:  Denies any cough or wheezing.  ,GI:  Positive for constipation, no bowel movements for 2 days.  ,GU:  Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling.  ,NEUROLOGIC:  Denies any lethargy or seizure.  ,MUSCULOSKELETAL:  No pain or swelling.  ,SKIN:  Erythema and edema in the pubic area for the last 3 days.  All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin.  The transfer labs are as follows:  15.7 for WBC, H&H 12.0 and 36.  One blood culture.  We will follow the results.  He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied.  ,PAST SURGICAL HISTORY:,  The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations.  He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:,  He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke.  There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature max at ER is 102, heart rate 153.,GENERAL:  This patient is alert, arousable, big boy.,HEENT:  Head:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Mucous membranes are moist.,NECK:  Supple.,CHEST:  Clear to auscultation bilaterally.  Good air exchange.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  Full range of movement.  No deformities.
Pulmonary Consultation - 2 
Medical specialty:  Consult - History and Phy.
 Patient with complaints of significant coughing and wheezing.

PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.
Pulmonary Edema - Consult 
Medical specialty:  Consult - History and Phy.
 This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure. 

HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.
Records Review - Orthopedic 
Medical specialty:  Consult - History and Phy.
 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed.   A screw had come loose.

Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial