smoh/medical-transcriptions huggingface dataset:
Well-Child Check - 2  ( Consult - History and Phy.)
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.
Well-Child Check - 1  ( Consult - History and Phy.)
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.
Weight Loss Evaluation  ( Consult - History and Phy.)
Description:  Patient with morbid obesity.

REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,
Viral Gastroenteritis  ( Consult - History and Phy.)
Description:  Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill.

HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine."  She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.
Weight Gain and Edema  ( Consult - History and Phy.)
Description:  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.

HISTORY OF PRESENT ILLNESS:,  This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.  She has noticed increasing abdominal girth as well as increasing edema in her legs.  She has been on Norvasc and lisinopril for years for hypertension.  She has occasional sweats with no significant change in her bowel status.  She takes her thyroid hormone apart from her Synthroid.  She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec.  Her amlodipine and lisinopril are on hold.,ALLERGIES:,  Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:,  As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds.  Denies chest pain or palpitations.  She has some loosening stools, but denies abdominal pain.  Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL:  She is an obese female.,VITAL SIGNS:  Blood pressure 140/70 and heart rate 84.  She is afebrile.,HEENT:  She has no periorbital edema.  Extraocular movements were intact.  There was moist oral mucosa.,NECK:  Supple.  Her thyroid gland is atrophic and nontender.,CHEST:  Good air entry.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Benign.,EXTREMITIES:  Showed 1+ edema.,NEUROLOGIC:  She was awake and alert.,LABORATORY DATA:,  TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:,  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago.  She is clinically and biochemically euthyroid.  Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine.  I will continue on 300 mcg daily of Synthroid.  If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.
Urology Consut - 1  ( Consult - History and Phy.)
Description:  Blood in urine - Transitional cell cancer of the bladder.

CHIEF COMPLAINT:,
Uveitis  ( Consult - History and Phy.)
Description:  The patient with recurrent nongranulomatous anterior iritis and most recently, pain in  left eye associated with headache and photophobia.

PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:,  Positive for only for left knee arthritis.  She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers.  She has no skin rashes.  She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left.  There is an afferent pupillary defect on the right.  On examination, there is a right hypertropia.  There is dense anterior chamber inflammation on the right eye with a stagnant aqueous.  There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern.  This seems to be complete iris synechia to the anterior lens capsule.  There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface.  The anterior chamber appears narrow.  On the left, there is also dense inflammation at 4+ cell.  There is 1+ nuclear sclerosis.  Dilated fundus examination cannot be performed on the right secondary to intense inflammation.  On the left, there is no evidence of active posterior uveitis.  There is some inferior vitreous debris.,ASSESSMENT/PLAN:,  Chronic bilateral recurrent nongranulomatous diffuse uveitis.  Currently, there is very severe right eye inflammation and severe left eye.  I discussed at length with the patient that this will likely take an oral steroid to quite her down.  Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible.  She has been on oral steroids in the past.  We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left.  I anticipate we will likely start methotrexate in the near future.  In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate.  We will watch her closely in clinic.  I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past.  At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR.  Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.
Vertigo Consult  ( Consult - History and Phy.)
Description:  The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.

Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid.  ,PLAN:  ,Planned for  electronystagmography to document the degree of vestibular hypofunction.,
Ureteral Calculus - Consult  ( Consult - History and Phy.)
Description:  Right distal ureteral calculus.  The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  

CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS:  ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.,PAST MEDICAL HISTORY:,1.  Prostatism.,2.  Coronary artery disease.,PAST SURGICAL HISTORY:,1.  Right spermatocelectomy.,2.  Left total knee replacement in 1987.,3.  Right knee in 2005.,MEDICATIONS:,1.  Coumadin 3 mg daily.,2.  Fosamax.,3.  Viagra p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS:,  CARDIOPULMONARY:  No shortness of breath or chest pain.  GI:  No nausea, vomiting, diarrhea or constipation.  GU:  Voids well.  MUSCULOSKELETAL:  No weakness or strokes.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  An alert male in no distress.,HEENT:  Grossly normal.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Normal sinus rhythm.  No murmur or gallop.,ABDOMEN:  Soft.  No masses.,GENITALIA:  Normal penis.  Testicles descended bilaterally.,RECTAL:  Examination benign.,EXTREMITIES:  No edema.,IMPRESSION: , Right distal ureteral calculus.,PLAN: , Right ureteroscopy, ureteral lithotripsy.  Risks and complications discussed with the patient.  He signed a true informed consent.  No guarantees or warrantees were given.
Vertigo Consult - 1  ( Consult - History and Phy.)
Description:  The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness.  Symptoms are not accompanied by tinnitus or deafness. 

Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability with difficulty.,Frenzel glasses examination: no spontaneous, end gaze nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,HEAD SHAKING AND VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, were done with difficulty a short corrective saccades may give the possibility if having a decompensated vestibular hypofunction. ,IMPRESSION:, Decompensation vestibular hypofunction documented by further electronystagmography and caloric testing. ,PLAN:,  Booked for electronystagmography and advised to continue with her vestibular rehabilitation exercises, in addition to supportive medical treatment in the form of betahistine 24 mg twice a day.
Trouble Breathing - H&P   ( Consult - History and Phy.)
Description:  History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.

CHIEF COMPLAINT: , "I have had trouble breathing for the past 3 days",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days.  He also states that he has been coughing accompanying with low-grade type fever.  He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,PMH: , DM, HTN, COPD, CAD,PSH:  ,CABG, appendectomy, tonsillectomy,FH:,  Non-contributory,SOCH: , Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  He smokes 1 pack a day of Newport for 30 years and is a social drinker.  He denies any illicit drug use.,TRAVEL HISTORY: , Denies any recent travel overseas,ALLERGIES: , Denies any drug allergies,HOME MEDICATIONS:,  Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:,  Same as above,PHYSICAL EXAM:,Vital signs are:  Temp.  99.3 F / BP 138/92, Resp.  22, P 88,General:  Patient is in mild acute respiratory distress,HEENT:,Head:  Atraumatic, normocephalic,,Eyes:
URI & Eustachian Congestion  ( Consult - History and Phy.)
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.