smoh/medical-transcriptions huggingface dataset:
Discharge Summary - 15  ( General Medicine)
Description:  Gastroenteritis and autism.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. 

FINAL DIAGNOSES:,1.  Gastroenteritis.,2.  Autism.,DIET ON DISCHARGE:,  Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.  She developed vomiting 3 days prior to admission, but did not have diarrhea.  She voided on the day of admission.  When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight.  She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA:  ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64.  Chest x-ray and abdominal films were unremarkable.  Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800.  Urinalysis was negative for ketones.  Specific gravity 1.023, and negative for protein.  Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118.  Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE:  ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated.  On the second hospital day, mother was comfortable taking her to home.  Mother did not have a good explanation for the weight loss.  In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94.  Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge.  We will follow up in the office and try to further evaluate her for the unexplained weight loss.  She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss.  The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.
Discharge Summary - 11  ( General Medicine)
Description:  Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.

ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC is a 57-year-old woman.  She suffers from morbid obesity.  She also has diabetes and obstructive sleep apnea.  She was evaluated in the Bariatric Surgical Center for placement of a band.  During her workup, she was noted to have evidence of cholelithiasis.  It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band.  The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438.  She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital.  She was seen by Dr. A.  He put her on an insulin drip.  Her sugars slowly did come down to normal down to between 115 and 134.  On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy.  She was noted to be a difficult intubation for the procedure.  There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder.  She underwent the procedure.  She tolerated without difficulty.  She was recovered in the Postoperative Care Unit and then returned to the floor.  Her blood sugar postprocedure was noted to be 233.  She was started back on a sliding scale insulin.  She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS:  ,To return to the Medifast diet.  To continue with her blood glucose.  She needs to follow up with Dr. B, and she will see me next week on Friday.  We will determine if we will proceed with her lap band at that time.  She may shower.  She needs to keep her wounds clean and dry.  No heavy lifting.  No driving on narcotic pain medicines.  She needs to continue with her CPAP machine and continue to monitor her sugars.
Discharge Summary - 14  ( General Medicine)
Description:  The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. 

HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.
Diabetes Mellitus - SOAP Note - 2  ( General Medicine)
Description:  Patient today with ongoing issues with diabetic control.

SUBJECTIVE:,  I am asked to see the patient today with ongoing issues around her diabetic control.  We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals.  Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change.  What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  The staff reports to me that her appetite is good and that she is eating as well as ever.  I talked to Anna today.  She feels a little fatigued.  Otherwise, she is doing well.,PHYSICAL EXAMINATION:  ,Vitals as in the chart.  The patient is a pleasant and cooperative.  She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning.  To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning.  She will get 55 units in the morning.  I am also decreasing once again her Humalog sliding scale insulin prior to meals.  I will review the blood glucoses again next week.,
Detox from Heroin  ( General Medicine)
Description:  A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.

CHIEF COMPLAINT:,  Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain.  He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS:  ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  Denies any headache or visual complaints.  No hallucinations.  No chest pain, shortness of breath, abdominal pain or back pain.  Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker.  Admits to heroin use, alcohol abuse as well.  Also admits today using cocaine.,FAMILY HISTORY:,  Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically.  Apparently, he just recently got out of prison.  He has previously also been on Klonopin and lithium.  He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient is afebrile.  He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  His respiratory rate is normal at 18.  GENERAL:  The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  HEENT:  Unremarkable.  Pupils are actually moderately dilated about 4 to 5 mm, but reactive.  Extraoculars are intact.  His oropharynx is clear.  NECK:  Supple.  His trachea is midline.  LUNGS:  Clear.  He has good breath sounds and no wheezing.  No rales or rhonchi.  Good air movement and no cough.  CARDIAC:  Without murmur.  ABDOMEN:  Soft and nontender.  He has multiple track marks, multiple tattoos, but no abscesses.  NEUROLOGIC:  Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN:  ,At this time, I think the patient can be followed up at XYZ.  I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy.  I do not think he needs any further workup at this time.  He is discharged otherwise in stable condition.
Discharge Summary - 12  ( General Medicine)
Description:  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.

CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.
Consult - Hypertension  ( General Medicine)
Description:  Patient with a past medical history of hypertension for 15 years.

HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.
Consult - Smoking Cessation   ( General Medicine)
Description:  The patient needs refills on her Xanax

CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.
Diabetes Mellitus - SOAP Note - 1  ( General Medicine)
Description:  Followup diabetes mellitus, type 1.

CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:
Consult - Coronary Artery Disease  ( General Medicine)
Description:  Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG: