smoh/medical-transcriptions huggingface dataset:
Overactive Bladder  ( SOAP / Chart / Progress Notes)
Description:  Overactive bladder with microscopic hematuria.

REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder.  Her cystoscopy performed was unremarkable.  She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night.  No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms.  The patient had been previously on Ditropan and did not do nearly as well.  At this point, what we will try is a different medication.  Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted.  She has no other significant findings other than her overactive bladder, which had continued.  At this juncture what I would like to do is try a different anticholinergic medication.  She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan.  We will start Sanctura XR and we will follow up as scheduled.  Otherwise we will continue to follow her urinalysis over the next year or so.
ORIF Facial Fractures - Followup  ( SOAP / Chart / Progress Notes)
Description:  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.

Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.
Possible Spider Bite  ( SOAP / Chart / Progress Notes)
Description:  A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.

SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.
Poison Ivy - SOAP  ( SOAP / Chart / Progress Notes)
Description:  Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.
ORIF - Followup  ( SOAP / Chart / Progress Notes)
Description:  Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.

REASON FOR VISIT:,  Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture.  The patient states that this pain is well controlled.  He has had no fevers, chills or night sweats.  He has had some mild drainage from his pin sites.  He just started doing range of motion type exercises for his right knee.  He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema.  There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted.  The patient had 3/5 strength in the EHL, FHL.  He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee.  It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee.  I would like to really work on this as he has not had much up to this time.  He should remain nonweightbearing.  I would like to have him return in 2 weeks' time to assess his knee range of motion.  He should not need x-rays at that time.
Ophthalmology Progress Note - 2  ( SOAP / Chart / Progress Notes)
Description:  Ophthalmology followup visit note.

A fluorescein angiogram was ordered at today's visit to rule out macular edema.  We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress.  A copy of the angiogram is enclosed for your records.
Osteoarthritis - Progress Note  ( SOAP / Chart / Progress Notes)
Description:  Orthopedic progress note for follow up of osteoarthritis, knees.

CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great.  Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain:  Localized to the bilateral knees right worse than left.,Quality:  There is no swelling, no redness, or warmth.  The pain is described as aching occasionally.  There is no burning. ,Duration:  Months.,Associated symptoms:  Includes stiffness and weakness.  There is no sleep loss and no instability.  ,Hip Pain:  None. ,Back pain: None. ,Radicular type pain:  None. ,Modifying factors: Includes weight bearing pain and pain with ambulation.  There is no sitting, and no night pain.  There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:,  No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living.  ,REVIEW OF SYSTEMS:,  No change.,Constitutional:  Good appetite and energy.  No fever.  No general complaints.,HEENT:  No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP:  No shortness of breath at rest or with exertion.  No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum.  No chest pain on exertion.,GI:
Ophthalmology Progress Note - 1  ( SOAP / Chart / Progress Notes)
Description:  Ophthalmology followup visit note.

She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.
MGUS Followup  ( SOAP / Chart / Progress Notes)
Description:  MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.

CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and 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: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:
Nephrolithiasis - Progress Note  ( SOAP / Chart / Progress Notes)
Description:  Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.

SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.
Mesothelioma - Chart Note  ( SOAP / Chart / Progress Notes)
Description:  A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.

The patient's home regimen includes Duragesic patch at 125 mcg every 3 days.  She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum.  The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block.  The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either.  For the moment, we will not make any further recommendations on her current medical management.  We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time.,
Multiple Progress Notes  ( SOAP / Chart / Progress Notes)
Description:  Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.

PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:,S: Sedated and intubated, one episode NSVT,O: ABGs: 7.38/67/86/97,4/19/01:,S: Sedated and intubated, scant blood material from NGT,A/P: 1) Respiratory arrest,2) Exacerbation COPD - gastro cath NG aspiration,4/20/01:,S: Intubated/sedated, w/ NAD,O: Pulmonary - Increase L. basilar inspiration,A/P: Pneumonia,Respiratory arrest,COPD exacerbation,New onset low grade fever,D/C NGT - suspect sensitivity,4/20/01:,O: Preliminary blood culture gram + cocci,Dr. A called w/ result, no orders left,Pt. afebrile, WBC increase to 20.2,ABGs improved from 4/20/01, pt. noted to have less secretions,Last night had 8 beat run V-Tach,4/21/01:,O: Chest x-rays reviewed - improvement in lower lobe infiltrate,Gram + cocci in blood,Sputum H. influen. gram neg.,4/22/01:,atient up in chair,Decrease ventilator support,Preliminary blood cultures - Staph coag neg 1 of 2,04/23/01:,S: Awake, alert in NAD,O: Temp 99.8,Blood cultures: Staph coag. Neg. 1 of 2,A/P: Pneumonia, respiratory arrest, COPD,Continue wearing tirals,4/24/01:,S: Awake and alert, +N, refused trach,If fails extubation, will allow for reintubation
Multiple Medical Problems  ( SOAP / Chart / Progress Notes)
Description:  Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)

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.
Non-Hodgkin lymphoma Followup  ( SOAP / Chart / Progress Notes)
Description:  Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy. 

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:
Neurologic Examination  ( SOAP / Chart / Progress Notes)
Description:  Neurologic examination sample.  

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.