smoh/medical-transcriptions huggingface dataset:
Hysterectomy - Discharge Summary - 2  ( Discharge Summary)
Description:  Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix.

ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.
Knee Arthroplasty - Discharge Summary  ( Discharge Summary)
Description:  Painful right knee status post total knee arthroplasty many years ago.   Status post poly exchange, right knee, total knee arthroplasty.

ADMISSION DIAGNOSIS:,  Painful right knee status post total knee arthroplasty many years ago.  The patient had gradual onset of worsening soreness and pain in this knee.  X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:,  Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:,  Stable.,PROCEDURES PERFORMED:,  Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE:  ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components.  The patient recovered well after this.  Working with PT, she was able to ambulate with minimal assistance.  Nerve block was removed by anesthesia.  The patient did well on oral pain medications.  The patient was discharged home.  She is actually going to home with her son who will be able to assist her and look after her for anything she might need.  The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son.  Diet is regular.  Activity, weight bear as tolerated right lower extremity.  Continue to do physical therapy exercises.  The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.  Vicodin 5/500 mg take one to two tablets p.o. q.4-6h.  Resume home medications.  Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision.  The patient is to follow up with Dr. ABC in two weeks.
Knee Osteoarthrosis - Discharge Summary  ( Discharge Summary)
Description:  A 66-year-old female with knee osteoarthrosis who failed conservative management.

PRINCIPAL DIAGNOSIS:,  Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:,  A 66-year-old female with knee osteoarthrosis.  Failed conservative management.  Risks and benefits of different treatment options were explained.  Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL:  Female who appears younger than her stated age.  Examination of her gait reveals she walks without assistive devices.,HEENT:  Normocephalic and atraumatic.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007.  She underwent right total knee arthroplasty.  She tolerated this well.  She was taken to the recovery room.  After uneventful recovery room course, she was brought to regular surgical floor.  Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated.  Routine postoperative antibiotics were administered.  Hemovac drain was discontinued on postoperative day #2.  Physical therapy was initiated.  Continuous passive motion (CPM) was also initiated.  She was able to spontaneously void.  She transferred to oral pain medication.  Incision remained clean, dry, and intact during the hospital course.  No pain with calf squeeze.  She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION:  ,Discharged to home.,FOLLOW UP:,  Follow up with Dr. X in one week.  Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.,
Hysterectomy - Discharge Summary - 1  ( Discharge Summary)
Description:  Total vaginal hysterectomy.   Menometrorrhagia, dysmenorrhea, and small uterine fibroids.

ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.
Hemiarthroplasty - Discharge Summary  ( Discharge Summary)
Description:  Hemiarthroplasty, right hip.  Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.

ADMISSION DIAGNOSES:  ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED:  ,Hemiarthroplasty, right hip.,CONSULTATIONS:  ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip.  The patient was admitted to Orthopedics and consulted Medicine.  The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence.  The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's.  Brief elevation of white count following the surgery, which did subside.  Studies, UA and blood culture were negative.  The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:,  Transfer to ABC for rehab and continued care.  Diabetic diet.  Activity, ambulate as tolerated with posterior hip precautions.  Rehab potential fair.  He will need nursing, Social Work, PT/OT, and nutrition consults.  Resume home meds, DVT prophylaxis, aspirin, and compression stockings.  Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.
Intrauterine Pregnancy - Discharge Summary  ( Discharge Summary)
Description:  Intrauterine pregnancy at term with previous cesarean.   Desired sterilization.  Status post repeat low transverse cesarean and bilateral tubal ligation.

ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.
GI Bleed - Discharge Summary  ( Discharge Summary)
Description:  GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia.

CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.
Hysterectomy - Discharge Summary  ( Discharge Summary)
Description:  The patient underwent a total vaginal hysterectomy.

ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.
Hypothermia - Discharge Summary   ( Discharge Summary)
Description:  Hypothermia.  Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.  Organic brain syndrome.  Seizure disorder.  Adrenal insufficiency.  Hypothyroidism.  Anemia of chronic disease.

DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted through the emergency room.  He was admitted to the Intensive Care Unit.  He was rewarmed and had blood, sputum, and urine cultures done.  He was placed on IV Rocephin.  His usual medications of Dilantin and Depakene were given.  The patient's hypertension was treated with fluid boluses.  The patient was empirically placed on Synthroid and hydrocortisone by Dr. X.  Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  H&H was stable at 33.3/10.9 and platelets of 80,000.  White blood cell counts were normal, differential was normal.  TSH was 3.41.  Free T4 was 0.9.  Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement.  A cortisol level was obtained prior to administration of hydrocortisone.  This was 10.9 and that was not a fasting level.  Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef.  The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday.  The patient was started back on his tube feeds.  He tolerated these poorly with residuals.  Reglan was increased to 10 mg q.6 h. and erythromycin is being added.  The patient's temperature has been stable in the 94 to 95 range.  Other vital signs have been stable.  His urine output has been diminished.  An external jugular line was placed in the Intensive Care Unit.  The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there.  As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him.  He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque.  His prognosis is poor.
Gastric Bypass Summary  ( Discharge Summary)
Description:  Patient discharged after laparoscopic Roux-en-Y gastric bypass.

FINAL DIAGNOSES,1.  Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. ,2.  Hypertension. ,3.  Obstructive sleep apnea, on CPAP.,OPERATION AND PROCEDURE: , Laparoscopic Roux-en-Y gastric bypass.,BRIEF HOSPITAL COURSE SUMMARY:  ,This is a 30-year-old male, who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities.  Underwent standard bariatric evaluation, consults, diagnostics, and preop Medifast induced weight loss in anticipation of elective bariatric surgery. ,Taken to the OR via same day surgery process for elective gastric bypass, tolerated well, recovered in the PACU, and sent to the floor for routine postoperative care.  There, DVT prophylaxis was continued with subcu heparin, early and frequent mobilization, and SCDs.  PCA was utilized for pain control, efficaciously, he utilized the CPAP, was monitored, and had no new cardiopulmonary complaints.  Postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well.  He was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms.  By the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today.  He had his drains removed today as well.,DISCHARGE INSTRUCTIONS: , Include re-appointment in the office in the next week, call in the interim if any significant concerning complaints.  Scripts left in the chart for omeprazole and Lortab.  Med rec sheet completed (on no meds).  He will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining.  Can shower starting tomorrow, drain site care and wound care reviewed.  He will re-appoint in the office in the next week, certainly call in the interim if any significant concerning complaints.
Gastroenteritis - Discharge Summary  ( Discharge Summary)
Description:  Acute gastroenteritis, resolved.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.

ADMITTING DIAGNOSES,1.  Acute gastroenteritis.,2.  Nausea.,3.  Vomiting.,4.  Diarrhea.,5.  Gastrointestinal bleed.,6.  Dehydration.,DISCHARGE DIAGNOSES,1.  Acute gastroenteritis, resolved.,2.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs.  The patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  The patient also denied any abdominal pain upon day of discharge.  The patient was also started on prednisone as per GI recommendations.  He was started on 60 mg p.o.  Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home.  He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair.  We will also start him on a tapered dose of prednisone for 4 weeks.  We will start him on 15 mg p.o. for seven days.  Then, week #2, we will start him on 40 mg for 1 week.  Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations.
Gastrointestinal Bleed - Discharge Summary  ( Discharge Summary)
Description:  Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.

DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:,  Colonoscopy.,FINDINGS:,  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood.  Dr. Y Miller saw him in consultation and recommended a colonoscopy.  A bowel prep was done.  H&Hs were stable.  His most recent H&H was 38.6/13.2 that was this morning.  His H&H at admission was 41/14.3.  The patient had the bowel prep that revealed no significant bleeding.  His vital signs are stable.  He is continuing on his usual medications of Imdur, metoprolol, and Synthroid.  His Plavix is discontinued.  He is given IV Protonix.  I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8.  Chemistry panel was unremarkable.  The patient was given a regular diet after his colonoscopy today.  He tolerated it well and is being discharged home.  He will be followed closely as an outpatient.  He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission.  He will hold his Plavix for now.  They will call me for further dark stools and will avoid Pepto-Bismol.  They will follow up in the office on Thursday.