smoh/medical-transcriptions huggingface dataset:
Psych Consult - Bipolar Affective Disorder  ( Consult - History and Phy.)
Description:  A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.

IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.
Prostate Adenocarcinoma - H&P  ( Consult - History and Phy.)
Description:  Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical

HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes.  He has a PSA of 3.1, with a prostate gland size of 41 grams.  This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left.  He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant.  Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease.  Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting.  History of high blood pressure, as well.  He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:,  Penicillin.,SOCIAL HISTORY:,  He is not a smoker.  He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT:  Examination unremarkable.,Breasts:  Examination deferred.,Chest:  Clear to auscultation.,Cardiac:  Regular rate and rhythm.,Abdomen:  Soft and nontender.  He has no hernias.,Genitourinary:  There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities:  Examination unremarkable.,Neurologic:  Examination nonfocal.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Erectile dysfunction.,PLAN:  ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy.  The risks, benefits, and alternatives of this have been discussed.  He understands and asks that I proceed ahead.  We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.
Prostate Adenocarcinoma  ( Consult - History and Phy.)
Description:  Adenocarcinoma of the prostate.  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. 

ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.
Pneumothorax & Subcutaneous Emphysema  ( Consult - History and Phy.)
Description:  Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.

REASON FOR CONSULTATION:,  Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain.  The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice.  The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings.  The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:,  Not contributory.,PHYSICAL EXAMINATION:,GENERAL:  Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  Trachea is midline.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender, and nondistended.  Normoactive bowel sounds.,EXTREMITIES:  No clubbing, edema, or cyanosis.,SKIN:  The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:,  As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.  These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:,  At this time, the CT Surgery service has been consulted and has left recommendations.  The patient also is awaiting bronchoscopy per the Pulmonary Service.  At this time, there are no General Surgery issues.
Postop Medical Management  ( Consult - History and Phy.)
Description:  Post-surgical medical management; right total knee replacement.

REASON FOR CONSULTATION: , Post-surgical medical management.,PROCEDURE DONE: , Right total knee replacement.,MEDICAL HISTORY:,1.  Arthritis of the right knee.,2.  Hypertension.,PAST SURGICAL HISTORY: , Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.,MEDICATIONS: , Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin.,ALLERGIES: , MORPHINE.,HISTORY OF PRESENT COMPLAINT: , This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday.  The patient is admitted today to the surgical floor for postoperative management.  The patient tolerated the procedure well.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever, chills, or malaise.,ENT:  Unremarkable.,RESPIRATORY:  The patient denies shortness of breath, cough, or wheezing.,CARDIOVASCULAR:  No known heart problems.  No orthopnea, palpitations, syncopal episode, or pedal swelling.,GASTROINTESTINAL:  She denies nausea or vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGICAL:  No history of seizure or TIA.  Cognitive function is intact.,SOCIAL HISTORY:  ,The patient does not smoke.  She consumes alcohol moderately.,FAMILY HISTORY:  ,Positive for cancer.,PHYSICAL EXAMINATION:,GENERAL:  This is an 84-year-old lady who looks young for her age.,VITAL SIGNS:  Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air.  She is afebrile.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur is appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no pedal swelling.,LABORATORY DATA:  ,Hemoglobin has dropped from 12.6 to 10.2.  Hematocrit is 30.  Glucose is 125.  BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8.,ASSESSMENT AND PLAN:,1.  Right knee arthritis status post right total knee replacement.  The patient tolerated the procedure well.,2.  Anemia due to stated operative blood loss, would not require transfusion at this point.,3.  Hypertension, under control.  Continue current home medications.,4.  Deep vein thrombosis risk, prophylaxis as per surgeon.,5.  Gastrointestinal prophylaxis.,6.  Debility.  Continue physical therapy and occupational therapy.
Perioperative Elevated Blood Pressure  ( Consult - History and Phy.)
Description:  Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. 

REASON FOR CONSULTATION:,  Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1.  Graves disease.,2.  Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3.  Diverticulosis.,4.  GERD.,5.  High blood pressure.,6.  Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT:  ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today.  Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.  Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking.  On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No recent fever or general malaise.,ENT:  Unremarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  No chest pain.,GASTROINTESTINAL:  No nausea or vomiting.,GENITOURINARY:  The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE:  Negative for diabetes, but positive for Graves disease.,MEDICATIONS:  ,The patient takes Synthroid and aspirin.  Aspirin had been discontinued about 1 week ago.  He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL:  A 71-year-old gentleman, not in acute distress.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,ASSESSMENT AND PLAN:,1.  Perioperative hypertension.  We will restart lisinopril at half the previous dose.  He will be on 20 mg p.o. daily.  If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily.  The patient should see his primary physician, Dr. Y in 2 weeks' time.  If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2.  Prostatic hypertrophy, status post laser surgery.  The patient tolerated the procedure well.,3.  History of Graves disease.,4.  History of atrial fibrillation.  The patient is in normal sinus rhythm.,DISPOSITION:  ,The patient is stable to be discharged to home.  Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.
Peripheral Effusion - Consult  ( Consult - History and Phy.)
Description:  Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. 

REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.
Pain Management Consult - 2  ( Consult - History and Phy.)
Description:  Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,
Orthopedic Consult - 4  ( Consult - History and Phy.)
Description:  Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. 

CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005.  Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain.  He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain.  Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain.  He states that approximately 75% of his pain is in his buttock and leg and 25% in his back.  He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back.  He rated his pain today as 6/10, describing it is shooting, sharp and aching.  It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication.  It is constant but variable in degree.  It continues to affect activities and sleep at night as well as mood at times.  He is currently not satisfied completely with his level of pain relief.,MEDICATIONS: , Kadian 30 mg b.i.d., Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n.,ALLERGIES:,  No known drug allergies.,REVIEW OF SYSTEMS:,  Complete multisystem review was noted and signed in the chart.,SOCIAL HISTORY:,  Unchanged from prior visit.,PHYSICAL EXAMINATION: , Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs.  He is a well-developed obese male in no acute distress.  He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression.  He ambulates with normal gait and has normal station.  He is able to heel and toe walk.  He denies any sensory changes.,ASSESSMENT & PLAN: , This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.  We discussed treatment options at length and he is willing to undergo a trial of Lyrica.,He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime.  We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him.  We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him.  He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.