smoh/medical-transcriptions huggingface dataset:
Well-Child Check - 4  ( Pediatrics - Neonatal)
Description:  1-year well child check.

SUBJECTIVE:,  The patient presents with Mom and Dad for her 1-year well child check.  The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Allergies:  None.  Medications:  Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,  Weight 24 pounds 1 ounce.  Height 30 inches.  Head circumference 46.5 cm.  Temperature afebrile.,General:  A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is closed.  Pupils equally round and reactive.  Sclerae are clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.  Good dentition.  Drooling and chewing with teething behavior today.  Neck is supple.  No lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze.  No crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No mass.  No organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1.  Well 1-year-old white female.,2.  Anticipatory guidance.  Reviewed growth, diet development and safety issues as well as immunizations.  Will receive Pediarix and HIB today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available.  Gave 1-year well child checkup handout to Mom and Dad.,3.  Follow up for the 15-month well child check or as needed for acute care.
Well-Child Check - 2  ( Pediatrics - Neonatal)
Description:  A 9-month well-child check.

SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,NECK:  Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm, without murmur.,ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.  No masses or organomegaly to palpation.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.
Tympanostomy & Myringotomy Tube Placement  ( Pediatrics - Neonatal)
Description:  Bilateral tympanostomy with myringotomy tube placement.    The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. 

PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.
URI & Eustachian Congestion  ( Pediatrics - Neonatal)
Description:  Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. 

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.
Well-Child Check - 1  ( Pediatrics - Neonatal)
Description:  Well child - Left lacrimal duct stenosis

CHIEF COMPLAINT:,  Well-child check.,HISTORY OF PRESENT ILLNESS:,  This is a 12-month-old female here with her mother for a well-child check.  Mother states she has been doing well.  She is concerned about drainage from her left eye.  Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning.  She states it is worse when the child gets a cold.  She has been using massaging when she can remember to do so.  The patient is drinking whole milk without problems.  She is using solid foods three times a day.  She sleeps well without problems.  Her bowel movements are regular without problems.  She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:,  Social:  She can feed herself with fingers.  She is comforted by parent’s touch.  She is able to separate and explore.  Fine motor:  She scribbles.  She has a pincer grasp.  She can drink from a cup.  Language:  She says dada.  She says one to two other words and she indicates her wants.  Gross motor:  She can stand alone.  She cruises.  She walks alone.  She stoops and recovers.,PHYSICAL EXAMINATION:,General:  She is alert, in no distress.,Vital signs:  Weight:  25th percentile.  Height:  25th percentile.  Head circumference:  50th percentile.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Left eye with watery secretions and crusted lashes.  Conjunctiva is clear.  TMs are clear bilaterally.  Nares are patent.  Mild nasal congestion present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Female external genitalia.,Extremities:  Symmetrical.  Femoral pulses are 2+ bilaterally.  Full range of motion of all extremities.,Neurologic:  Grossly intact.,Skin:  Normal turgor.,Testing:  Hearing and vision assessments grossly normal.,ASSESSMENT:,1.  Well child.,2.  Left lacrimal duct stenosis.,PLAN:,  MMR #1 and Varivax #1 today.  VIS statements given to Mother after discussion.  Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct.  Anticipatory guidance for age.  She is to return to the office in three months.
Sports Physical - 3  ( Pediatrics - Neonatal)
Description:  Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.

SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.
Single Frontal View - Chest - Pediatric  ( Pediatrics - Neonatal)
Description:  Single frontal view of the chest. Respiratory distress.  The patient has a history of malrotation.

EXAM:,  Single frontal view of the chest.,HISTORY:,  Respiratory distress.  The patient has a history of malrotation.  The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:,  Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:,  A single frontal view of the chest was evaluated.  It reveals interval placement of an ET tube and an NG tube.  ET tube is midway between the patient's thoracic inlet and carina.  NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm.  There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.  The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique.  There is a slight increase seen with regards to the central pulmonary vessels.  Again, this may represent a minimal amount of pulmonary vascular congestion.  There is paucity of bowel gas seen in the upper abdomen.  The osseous thorax appears to be grossly intact and symmetrical.  Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1.  No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2.  Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3.  Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.
Rectal Bleeding - 1-year-old  ( Pediatrics - Neonatal)
Description:  Pediatric Gastroenterology - Rectal Bleeding Consult.

HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.
Slipped Capital Femoral Epiphysis (SCFE)  ( Pediatrics - Neonatal)
Description:  Frontal and lateral views of the hip and pelvis.

EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.
School Physical - 2  ( Pediatrics - Neonatal)
Description:  Well-child check and school physical.

CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.