smoh/medical-transcriptions huggingface dataset:
Normal Male Exam Template - 1  ( Office Notes)
Description:  An example/template for a routine normal male physical exam.

MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.
Normal Male Exam Template  ( Office Notes)
Description:  Sample/template for a normal male multisystem exam.

MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
Normal Male Exam Template - 4  ( Office Notes)
Description:  An example/template for a routine normal male physical exam.

VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.
Normal Female ROS Template  ( Office Notes)
Description:  Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.

CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.
Normal ENT Exam - 1  ( Office Notes)
Description:  Sample normal ear, nose, mouth, and throat exam.

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.
Nephrology Office Visit - 2  ( Office Notes)
Description:  Nephrology office visit for followup of CKD.

HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,
Normal ENT Exam  ( Office Notes)
Description:  Sample normal ear, nose, mouth, and throat exam.

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.
Normal Child Exam Template  ( Office Notes)
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.
Myoclonic Epilepsy  ( Office Notes)
Description:  Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.

DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.
Hip Pain  ( Office Notes)
Description:  Persistent left hip pain.  Left hip avascular necrosis.  Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing

CHIEF COMPLAINT:,
Normal Female Exam Template - 2  ( Office Notes)
Description:  An example/template for a routine normal female physical exam.

VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.
Normal Female Exam Template  ( Office Notes)
Description:  Sample/template for a normal female multisystem exam

MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES: , The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,BREASTS:  ,Breast inspection showed them to be symmetrical with no nipple discharge.  Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL:  ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU:  ,The external genitalia appeared to be normal.  The pelvic exam revealed no adnexal masses.  The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN:,  Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC:  ,The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
Nephrology Office Visit - 1  ( Office Notes)
Description:  Nephrology office visit for followup of microscopic hematuria.

HISTORY OF PRESENT ILLNESS:  ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria.  History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation.  The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease.  She does not use nonsteroidal agents.  She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision.  The patient has had decreased hearing for many years.  She has no abdominal pain or nausea or vomiting.  She has no anemia.  She has noticed no swelling.  She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia.  There is no history of heart attack or stroke.  She has had bilateral simple mastectomies done 35 years ago.  She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.)  She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow.  She does not smoke.,MEDICATIONS:,1.  Dyazide one a day.,2.  Pravachol 80 mg a day in the evening.,3.  Vitamin E once a day.,4.  One baby aspirin per day.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,  She looks younger than her stated age of 78 years.  She was hard of hearing, but could read my lips.  Respirations were 16.  She was afebrile.  Pulse was about 90 and regular.  Her gait was normal.  Blood pressure is 140/70 in her left arm seated.  HEENT:  She had arcus cornealis.  The pupils were equal.  The sclerae were not icteric.  The conjunctivae were pink.  NECK:  The thyroid is not palpated.  No nodes were palpated in the neck.  CHEST:  Clear to auscultation.  She had no sacral edema.  CARDIAC:  Regular, but she was tachycardic at the rate of about 90.  She had no diastolic murmur.  ABDOMEN:  Soft, and nontender.  I did not palpate the liver.  EXTREMITIES:  She had no appreciable edema.  She had no digital clubbing.  She had no cyanosis.  She had changes of the degenerative joint disease in her fingers.  She had good pedal pulses.  She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields.  She had no protein.  She did have many squamous cells.  The patient has creatinine of 1 mg percent and no proteinuria.  It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram.  I would also repeat a routine urinalysis to check for blood again.  I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram.
Constipation - 1  ( Office Notes)
Description:  Patient complains of constipation.  Has not had BM for two days.

Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General:  Pleasant, brighter.,Vital signs:  117/78, 12, 56.,Abdomen:  Soft, nontender.  Bowel sounds normal.,ASSESSMENT AND PLAN:,1.  Constipation.  Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2.  CAD/angina.  See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,
Headache - Office Visit  ( Office Notes)
Description:  The patient with continued problems with her headaches. 

She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.