smoh/medical-transcriptions huggingface dataset:
Consult - Syncope  ( General Medicine)
Description:  Patient was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. 

REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.  No palpitation.  Presently, he is comfortable, lying in the bed.  As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is borderline elevated.  No history of established coronary artery disease.  Family history noncontributory.,PAST MEDICAL HISTORY:  ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1.  Pain medications.,2.  Thyroid supplementation.,3.  Lovastatin 20 mg daily.,4.  Propranolol 20 b.i.d.,5.  Protonix.,6.  Flomax.,ALLERGIES:,  None.,PERSONAL HISTORY:,  He is married.  Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  No weakness, fatigue, or tiredness.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  No congestive heart failure.  No arrhythmias.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGIC:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.  No significant carotid bruits.,LUNGS:  Air entry is bilaterally decreased.,HEART:  PMI is displaced.  S1 and S2 are regular.,ABDOMEN:  Soft and nontender.  Bowel sounds are present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.  The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable.  White count of 14.  BUN and creatinine are within normal limits.  Cardiac enzyme profile is negative.  Ammonia level is elevated at 69.  CT angiogram of the chest, no evidence of pulmonary embolism.  Chest x-ray is negative for acute changes.  CT of the head, unremarkable, chronic skin changes.  Liver enzymes are within normal limits.,IMPRESSION:,1.  The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.
Congestion & Cough - 5-month-Old  ( General Medicine)
Description:  A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.
Cellulitis - Discharge Summary  ( General Medicine)
Description:  Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. 

DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.
Burn - Consult  ( General Medicine)
Description:  First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.
Buttock Abscess  ( General Medicine)
Description:  Left buttock abscess, status post incision and drainage.   Recommended some local wound care

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.
Care Conference With Family  ( General Medicine)
Description:  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.

REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.
Chest Pain & Respiratory Insufficiency  ( General Medicine)
Description:  A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina.

We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.
Asbestos Exposure - Hemoptysis  ( General Medicine)
Description:  Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.

REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics.
Admission History & Physical - Nausea  ( General Medicine)
Description:  Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago.  He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back.  He feels like he was on it but has not done so.  He has overall malaise and a low-grade temperature of 100.3.  He denies any prior similar or lesser symptoms.  His last normal bowel movement was yesterday.  He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS:  ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol.  He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS:  ,Otherwise negative.,PHYSICAL EXAMINATION:,  His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84.  He is drowsy, but easily arousable and appropriate with conversation.  He is oriented to person, place, and situation.  He is normocephalic, atraumatic.  His sclerae are anicteric.  His mucous membranes are somewhat tacky.  His neck is supple and symmetric.  His respirations are unlabored and clear.  He has a regular rate and rhythm.  His abdomen is soft.  He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding.  He otherwise has no organomegaly, masses, or abdominal hernias evident.  His extremities are symmetrical with no edema.  His posterior tibial pulses are palpable and symmetric.  He is grossly nonfocal neurologically.,STUDIES:,  His white blood cell count is 8.4 with 79 segs.  His hematocrit is 41.  His electrolytes are normal.  His bilirubin is 2.8.  His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics.  We will get an ultrasound this morning.  He will need his gallbladder out, probably with intraoperative cholangiogram.  Hopefully, the stone will pass this way.  Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted.  Dr. X will see him later this morning and discuss the plan further.  The patient understands.
Ant Bait Exposure - ER Visit  ( General Medicine)
Description:  Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.