smoh/medical-transcriptions huggingface dataset:
Small Bowel Obstruction  ( Consult - History and Phy.)
Description:  History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.

CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.1
Sepsis - Consult  ( Consult - History and Phy.)
Description:  Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  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 currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.
Shoulder Pain Consult  ( Consult - History and Phy.)
Description:  Consultation for right shoulder pain.

CHIEF COMPLAINT:,  Right shoulder pain.,HISTORY OF PRESENT PROBLEM:
Sports Physical - 2  ( Consult - History and Phy.)
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.
Rheumatoid Arthritis - Consult  ( Consult - History and Phy.)
Description:  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  ( Consult - History and Phy.)
Description:  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  ( Consult - History and Phy.)
Description:  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  ( Consult - History and Phy.)
Description:  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  ( Consult - History and Phy.)
Description:  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  ( Consult - History and Phy.)
Description:  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.