smoh/medical-transcriptions huggingface dataset:
Syncope - ER Visit - 1  ( Emergency Room Reports)
Description:  The patient had a syncopal episode last night.   She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.

REASON FOR VISIT:,  Syncope.,HISTORY:,  The patient is a 75-year-old lady who had a syncopal episode last night.  She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today.  She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink.  She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  Afebrile.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT:  ,Syncope.,PLAN:  ,She had a CT scan of the brain that was negative today.  The blood pressure is high.  We will start Maxzide.  We will do an outpatient Holter and carotid Doppler study.  She has had an echocardiogram along with the stress test before and it was normal.  We will do an outpatient followup.
Sickle Cell Anemia - ER Visit  ( Emergency Room Reports)
Description:  A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.

HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.
Pain from Hernia - ER Consult  ( Emergency Room Reports)
Description:  This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. 

HISTORY OF PRESENT ILLNESS:  ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.  At the time of my exam, he states that his left lower extremity pain has improved considerably.  He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably.  He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure.  He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS:  Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT:  Unremarkable.,LUNGS:  Clear.,CARDIOVASCULAR:  An irregular rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  His upper extremities are well perfused.  He has palpable radial and femoral pulses.  He does not have any palpable pedal pulses in either right or left lower extremity.  He does have reasonable capillary refill in both feet.  He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm.  Apparently, this was lot worst few hours ago.  He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent.  He currently has a viable extremity and viable foot, but certainly has significant making compromised flow.  It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention.  He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime.  Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization.  We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate.  Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity.  We will follow him along closely.
Nausea & Vomiting - ER Visit  ( Emergency Room Reports)
Description:  She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission.

HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , No alcohol, drugs, or tobacco.,PAST OBSTETRICAL HISTORY:  ,This is her first pregnancy.,PAST GYNECOLOGICAL HISTORY: , Not pertinent.,While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2.  Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria.  H and H stable at 14.1 and 48.7.  She was then admitted after giving some Phenergan and Zofran IV.  As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection.  She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food.  Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.,ASSESSMENT AND PLAN:,1.  This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.,2.  Slightly elevated ALT, questionable, likely due to the nausea and vomiting.  We will recheck for followup.
Mastoiditis - Discharge Summary  ( Emergency Room Reports)
Description:  Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  

DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.
Intracranial aneurysm - ER Visit  ( Emergency Room Reports)
Description:  Headache, improved.  Intracranial aneurysm.

CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.
Hydrocarbon Aspiration - ER Visit  ( Emergency Room Reports)
Description:  The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. 

SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,
Hematuria - ER Visit  ( Emergency Room Reports)
Description:  Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.

HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.
Headache - Urgent Care Visit  ( Emergency Room Reports)
Description:  Migraine headache - The patient was seen in the urgent care.

CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours.  She denies trauma.  She has been intermittently nauseated but has not vomited and has some photophobia.  Denies fever or change in vision.  She has no past history of headaches.  ,PMH: , None. ,MEDICATIONS:  ,Tylenol for pain.,ALLERGIES:,  None.,FAMILY HISTORY: , Grandmother died of cerebral aneurysm.  ,ROS:,  Negative.,PHYSICAL EXAM:  ,Vital Signs:  BP 102/60 P 70 RR 20 T 98.2 ,HEENT:  Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,Neck:  Supple without meningismus. ,Chest:  Lungs clear; heart regular without murmur.,COURSE IN THE ED: , The patient was seen in the urgent care and examined.  At this time, her photophobia and nausea make migraine highly likely.  She is well appearing and we'll try Tylenol with codeine for her pain.  One day off school and follow up with her primary doctor.  ,IMPRESSION: , Migraine headache.  ,PLAN: , See above.
High PT-INR - ER Visit  ( Emergency Room Reports)
Description:  Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.

REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.