smoh/medical-transcriptions huggingface dataset:
SOAP - Lung Mass  ( SOAP / Chart / Progress Notes)
Description:  Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation. 

SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.
SOAP - Numbness & Tingling  ( SOAP / Chart / Progress Notes)
Description:  Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.

SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.
SOAP - Temporal Mass  ( SOAP / Chart / Progress Notes)
Description:  MRI demonstrated right contrast-enhancing temporal mass.

SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.
Shortness Of Breath - Progress Note  ( SOAP / Chart / Progress Notes)
Description:  The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. 

She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was "immune" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.
Refractory Hypertension - Followup  ( SOAP / Chart / Progress Notes)
Description:  Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.

PROBLEM LIST:,1.  Refractory hypertension, much improved.,2.  History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3.  History of GI bleed in 1995.,4.  History of depression.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for this patient.  She is an 85-year-old woman with history as noted above.  Her last visit was approximately four months ago.  Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously.  She is not reporting any untoward side effect.  She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing.  She has no orthopnea.  Her exercise capacity is about the same.  The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine.  No history of extremity pain.,CURRENT MEDICATIONS:,1.  Triamterene/hydrochlorothiazide 37.5/25 mg.,2.  Norvasc 10 mg daily.,3.  Atenolol 50 mg a day.,4.  Atacand 32 mg a day.,5.  Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56.  THORAX:  Revealed lungs that are clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3.  I could not hear murmur today.  ABDOMEN:  Above plane, but nontender.  EXTREMITIES:  Revealed no edema.,ASSESSMENT:,  This is a return visit for this patient who has refractory hypertension.  This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously.  We had discussed with her in the past beginning to see an internist at the senior center.  She apparently had an appointment scheduled and it was missed.  We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us.  In the meantime, we will discharge her from our practice.  Should there be confusion or difficulty getting in the senior center, we can always see her back in followup
Sexual Dysfunction - Chart Note  ( SOAP / Chart / Progress Notes)
Description:  A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis.

SUBJECTIVE:,  The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction.  Patient reports that he would like to try Cialis to see if it will improve his erectile performance.  Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in.  Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem.  In discussing with me directly, patient primarily expresses that he would like to have his erections last longer.  However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration.  However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse.  Patient has no significant past medical history.  He has never had any previous testicular infections.  He denies any history of injuries to the groin and he has never been told that he has a hernia.,CURRENT MEDICATIONS:,  None.,ALLERGIES: , No drug allergies.,SOCIAL: , Only occasionally drinks alcohol and he is a nonsmoker.  He currently is working as a nurse aid, second shift, at a nursing home.  He states that he did not enroll in Wichita State this semester.  Stating he just was tired and wanted to take some time off.  He states he is in a relationship with one partner and denies any specific stress in the relationship.,OBJECTIVE:,General:  He appears in no distress.,Vital Signs:  Blood pressure:  With large cuff is 120/90.,Lungs:  Clear to auscultation.,Cardiovascular:  Normal S1-S2 without murmur.,Abdomen:  Soft, nontender.  Femoral pulses are 2+.,GU:  Testicles descended bilaterally.  No evidence of masses.  No evidence of inguinal hernias.,ASSESSMENT:,  Sexual dysfunction.,PLAN:,  We will check a free and total testosterone level as he does note some diminished desire.  He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful.  He will follow up here p.r.n.  Lastly, I did give him a blood pressure recording card, as his blood pressure is borderline today.  He will have that checked weekly at his workplace and follow up if they remain elevated.
Rheumatology Progress Note  ( SOAP / Chart / Progress Notes)
Description:  Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.

SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.
Pulmonary Medicine Clinic Followup  ( SOAP / Chart / Progress Notes)
Description:  Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.

SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.  She was last seen in the clinic in March 2004.  Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable.  She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  She does have occasional cough and a small amount of sputum production.  No fever or chills.  No chest pains.,CURRENT MEDICATIONS:,  The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:,  Erythromycin.,REVIEW OF SYSTEMS:,  Significant for problems with agitated depression.  Her respiratory status is unchanged as noted above.,EXAMINATION:,General:  The patient is in no acute distress.,Vital signs:  Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular:  Distant heart tones.  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1.  Chronic obstructive pulmonary disease/emphysema, severe but stable.,2.  Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3.  History of depression and schizophrenia.,PLAN:,  At this point, I have recommended that she continue current respiratory medicine.  I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading.  I have recommended that she use it with activity and at night.  I spoke with her about her living situation.  Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment.  Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.
Recheck of ADHD Meds  ( SOAP / Chart / Progress Notes)
Description:  A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.

SUBJECTIVE:,  This is a 6-year-old male who comes in rechecking his ADHD medicines.  We placed him on Adderall, first time he has been on a stimulant medication last month.  Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine.  She has two concerns.  It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in.  It wears off about 2 and they have problems in the evening with him.  He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off.  His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible.  The patient even commented that he thought he needed his medication.,PAST HISTORY:,  Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:,  He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:,  Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:,  He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay.  Review of systems is otherwise negative.,OBJECTIVE:,  Weight is 46.5 pounds, which is down just a little bit from his appointment last month.  He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room.  Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:,  At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:,  Discussed with mother two options.  Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose.  As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer.  So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon.  Mother is to watch his diet.  We would like to recheck his weight if he is doing very well, in two months.  But if there are any problems, especially in the morning then we would do the Ritalin LA.  Mother understands and will call if there are problems.  Approximately 25 minutes spent with patient, all in discussion.
Pulmonary - Followup Note  ( SOAP / Chart / Progress Notes)
Description:  Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.

SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  She was last seen in the Pulmonary Medicine Clinic in January 2004.  Since that time, her respiratory status has been quite good.  She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  She denies any problems with cough or sputum production.  No fevers or chills.  Recently, she has had a bit more problems with fatigue.  For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:,  Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily.  She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:,  Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:,  Noncontributory except as outlined above.,EXAMINATION:,General:  The patient was in no acute distress.,Vital signs:  Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds, but clear.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.  No skin lesions.,O2 saturation was checked at rest.  On room air it was 96% and on ambulation it varied between 94% and 96%.  Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1.  Lupus with mild pneumonitis.,2.  Respiratory status is stable.,3.  Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:,  At this time, I have recommended to continue her current medications.  We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan.  At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.