smoh/medical-transcriptions huggingface dataset:
Foot Pain  ( Emergency Room Reports)
Description:  Patient dropped a weight on the dorsal aspects of his feet.

CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team.  He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet.  He was barefoot at that time.  He had been in the pool practicing an hour prior to this injury.  Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care.  He is able to bear weight; however, complains of pain in his toes.  The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot.  According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY:  ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,He does not use alcohol, tobacco or illicit drugs.  He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION:,GENERAL:  This is a pleasant white male in no acute distress.,VITAL SIGNS:  He is afebrile.  Vitals are stable and within normal limits.,HEENT:  Negative for acute evidence of trauma, injury or infection.,LUNGS:  Clear.,HEART:  Regular rate and rhythm with S1 and S2.,ABDOMEN:  Soft.,EXTREMITIES:  There are some abrasions across the dorsum of the right foot including the second, third and fourth toes.  There is some mild tenderness to palpation.  However, there are no clinical fractures.  Distal pulses are intact.  The left foot notes superficial avulsion lacerations to the third and fourth digit.  There are no subungual hematomas.  Range of motion is decreased secondary to pain.  No obvious fractures identified.,BACK EXAM:  Nontender.,NEUROLOGIC EXAM:  He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably.  He was informed of the x-ray findings.  The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable.  All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge.  The patient/family understood the instructions and was discharged without further incident.
Headache - Emergency Visit  ( Emergency Room Reports)
Description:  Muscle tension cephalgia.  Right trapezius and rhomboid muscle spasm.

CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:,  This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache.  She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago.  Indicates pressure type of discomfort with throbbing component.  It is as high as a 9 on a 0 to 10 scale of intensity.  She denies having had similar discomfort in the past.  Denies any trauma.,Review of systems:  No fever or chills.  No sinus congestion or nasal drainage.  No cough or cold symptoms.  No head trauma.  Mild nausea.  No vomiting or diarrhea.  Other systems reviewed and are negative.,PMH: , Acne.  Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single.  Living at home.  No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES:  ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS:  Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL:  This is a 16-year-old white female.  She is awake, alert, and oriented x3.  She does appear bit uncomfortable.,HEAD:  Normocephalic and atraumatic.,EYES:  The pupils were equal and reactive to light.  Extraocular movements are intact.,ENT:  TMs are clear.  Nose and throat are unremarkable.,NECK:  There is no evidence of nuchal rigidity.  She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles.  Palpation clearly causes having exacerbation of her discomfort.,CHEST:  Thorax is unremarkable.,GI:  Abdomen is nontender.,MUSCLES:  Extremities are unremarkable.,NEURO:  Cranial nerves II through XII are grossly intact.  Motor and sensory are grossly intact.  ,SKIN:  Skin is warm and dry.,ED COURSE:,  The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1.  Muscle tension cephalgia.,2.  Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20.  She was instructed to apply warm compresses and perform gentle massage.  Follow up with regular provider as needed.  Return if any problems.
ER Report - URI  ( Emergency Room Reports)
Description:  Patient in ER with upper respiratory infection

HISTORY OF PRESENT ILLNESS:,  The patient is a two-and-a-half-month-old male who has been sick for the past three to four days.  His mother has described congested sounds with cough and decreased appetite.  He has had no fever.  He has had no rhinorrhea.  Nobody else at home is currently ill.  He has no cigarette smoke exposure.  She brought him to the emergency room this morning after a bad coughing spell.  He did not have any apnea during this episode.,PAST MEDICAL HISTORY:,  Unremarkable.  He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL:  Sleeping, easily aroused, smiling, and in no distress.,HEENT:  Soft anterior fontanelle.  TMs are normal.  Moist mucous membranes.,LUNGS:  Equal and clear.,CHEST:  Without retraction.,HEART:  Regular in rate and rhythm without murmur.,ABDOMEN:  Benign.,DIAGNOSTIC STUDIES:,  Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:,  Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares.  Smaller but more frequent feeds.  Discuss proper sleeping position.  Recheck if there is any fever or if he is no better in the next three days.
Fall & Laceration  ( Emergency Room Reports)
Description:  Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.

CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.
Dental Pain  ( Emergency Room Reports)
Description:  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.

CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.
Consult/ER Report - OB/GYN  ( Emergency Room Reports)
Description:  A female with unknown gestational age who presents to the ED after a suicide attempt.

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
Chest Tube Insertion in ER  ( Emergency Room Reports)
Description:  Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.
Closed Head Injury  ( Emergency Room Reports)
Description:  Status post a high-speed motor vehicle accident in which patient was ejected from the vehicle.

CHIEF COMPLAINT:,  Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle.  He denies loss of consciousness, although the EMT people report that he did have loss of consciousness.  The patient was stable en route.  Upon arrival, he complained of headache.,PAST MEDICAL HISTORY:,  Medical:  None.  Surgical:  None.,REVIEW OF SYSTEMS: , CARDIAC:  No history.  PULMONARY:  Some morning cough.  (Patient is a smoker.),MEDICATIONS:,  None.,ALLERGIES:,  ALLERGIC TO PENICILLIN, CAUSES SKIN RASH.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°.,HEENT:  Contusion over right occipital area.  Tympanic membranes benign.,NECK:  Nontender.,CHEST:  Atraumatic, nontender.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Flat, soft, and nontender.,BACK:  Atraumatic, nontender.,PELVIS:  Stable,EXTREMITIES:  Contusion over right forearm.  No bone deformity or crepitus.,RECTAL:  Normal sphincter tone; guaiac negative.,NEUROLOGIC:  Glasgow coma scale 15.  Pupils equal, round, reactive to light.  Patient moves all 4 extremities without focal deficit.,LABORATORY DATA: , Serial hematocrits 42.4, and 40.4.  White blood count 6.3.  Ethanol:  None.  Amylase 66.  Urinalysis normal.  PT 12.6, PTT 29.  Chem-7 panel within normal limits.,X-rays of cervical spine and lumbosacral spine within normal limits.  X-rays of pelvis and chest within normal limits.,ASSESSMENT:,1.  Closed head injury.,2.  Rule out intra-abdominal injury.,PLAN:,  The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.
Asthma in a 5-year-old  ( Emergency Room Reports)
Description:  Mother states he has been wheezing and coughing.

CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma."  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.
Ankle pain  ( Emergency Room Reports)
Description:  Acute foot or ankle sprain, possible small fracture.

CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:
Airway Compromise & Foreign Body - ER Visit  ( Emergency Room Reports)
Description:  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.

HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.