smoh/medical-transcriptions huggingface dataset:
Sports Physical - 2  ( Pediatrics - Neonatal)
Description:  Well-child check sports physical - Well child asthma with good control, allergic rhinitis.

CHIEF COMPLAINT:,  Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:,  This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis.  He is here with his mother for a well-child check.  Mother states he has been doing well with regard to his asthma and allergies.  He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed.  His last exacerbation was 04/04.  He has been very competitive in his sports this spring and summer and has had no issues since that time.  He eats well from all food groups.  He has very good calcium intake.  He will be attending Maize High School in the ninth grade.  He has same-sex and opposite-sex friends.  He has had a girlfriend in the past.  He denies any sexual activity.  No use of alcohol, cigarettes or other drugs.  His bowel movements are without problems.  His immunizations are up to date.  His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:,  As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional:  He has had no fever.,HEENT:  No vision problems.  No eye redness, itching or drainage.  No earache.  No sore throat or congestion.,Cardiovascular:  No chest pain.,Respiratory:  No cough, shortness of breath or wheezing.,GI:  No stomachache, vomiting or diarrhea.,GU:  No dysuria, urgency or frequency.,Hematological:  No excessive bruising or bleeding.  He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress.,Vital signs:  He is afebrile.  His weight is at the 75th percentile.  His height is about the 80th percentile.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal, round and reactive to light.  TMs are clear bilaterally.  Nares patent.  Nasal mucosa is mildly edematous and pink.  No secretions.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Good air exchange bilaterally.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Male.  Testes descended bilaterally.  Tanner IV.  No hernia appreciated.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  Minor sunburn on upper back.,Neurological:  Grossly intact.,ASSESSMENT:,1.  Well child.,2.  Asthma with good control.,3.  Allergic rhinitis, stable.,PLAN:,  Hearing and vision assessment today are both within normal limits.  Will check an H&H today.  Continue all medications as directed.  Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue.  Anticipatory guidance for age.  He is to return to the office in one year or sooner if needed.
Prematurity - Discharge Summary  ( Pediatrics - Neonatal)
Description:  Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.

ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.
Pediatric - Letter  ( Pediatrics - Neonatal)
Description:  9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.

Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,
Pediatric Urology Letter  ( Pediatrics - Neonatal)
Description:  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. 

XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE:  XXXX, XXXX ,MR#:  0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic.  I appreciate you speaking with me while he was in clinic.  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side.  His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration.  They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially.  I think he should stay on MiraLax for management of his bowels.  I would also suggest that he be referred to Pediatric Gastroenterology for evaluation.  If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic.  If you have any questions, please feel free to contact me. ,Sincerely yours,
Pulmonary Hypertension - Pediatric Consult  ( Pediatrics - Neonatal)
Description:  Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.  

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.
Patent Ductus Arteriosus Ligation  ( Pediatrics - Neonatal)
Description:  Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. 

TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
Normal Newborn H&P Template  ( Pediatrics - Neonatal)
Description:  Template for History and Physical for a newborn.

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,
Normal Newborn Infant Physical Exam  ( Pediatrics - Neonatal)
Description:  Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress.

GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.
Neonatal Discharge Summary  ( Pediatrics - Neonatal)
Description:   The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.

HOSPITAL COURSE:,  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.  Baby was born at 5:57 on 07/30/2006.  Mother received ampicillin 2 g 4 hours prior to delivery.  Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate.  Baby was born with Apgar scores of 8 and 9 at delivery.  Fluid was cleared.  Nuchal cord x1.  Prenatal was at ABC Valley.  Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive.  Baby was suctioned on perineum with good support.  The baby was admitted to the NICU for prematurity and to rule out sepsis.  Baby's cry was good.  Color, tone, and __________ mild retractions.  CBC, CRP, blood cultures were done.  IV fluids of D10 at a rate of 6 mL an hour.  Ampicillin and gentamicin were started via protocol.  At the time of admission, the patient was stable on room air and has feeding issues.  Baby was fed EBM 22 and NeoSure per os.  Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours.  The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced.  Also, the baby was able to suck properly and was tolerating feeds.  The baby was fed EBM 22 and NeoSure was added a day before discharge.  At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:,  Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:,  Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006.  CPR teaching was completed on 08/11/2006 to parents.  Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed.  Ad lib feeding on demand.
Normal Child Exam Template  ( Pediatrics - Neonatal)
Description:  Normal child physical exam template.

CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.
Multiple Images of Skull (Pediatric)  ( Pediatrics - Neonatal)
Description:  Skull, complete, five images.

EXAM:,  Skull, complete, five images,HISTORY:,  Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated.  There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure.  There is no evidence of any craniosynostosis.  There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly.
Mastoiditis - Discharge Summary  ( Pediatrics - Neonatal)
Description:  Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  

DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.