smoh/medical-transcriptions huggingface dataset:
Gen Med Consult - 14  ( General Medicine)
Description:  Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis.

HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.
Gen Med Consult - 18  ( General Medicine)
Description:  1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough.

SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.
Gen Med Consult - 12  ( General Medicine)
Description:  Feeling weak and shaky - Dyspnea on exertion and history of diabetes

CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.
Gen Med Consult - 1  ( General Medicine)
Description:  Return to work & Fit for duty evaluation.

HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain.  He states that this began approximately one week ago when he was lifting stacks of cardboard.  The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level.  Sometimes he has to throw the stacks a little bit as well.  He states he felt a popping sensation on 06/30/04.  Since that time, he has had persistent shoulder pain with lifting activities.  He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder.  He has no upper extremity .  , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies.  He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.  , ,MEDICATIONS: , Claritin for allergic rhinitis.  , ,ALLERGIES: , None.  , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2.  He is sitting upright, alert and oriented, and in no acute distress.  Skin is warm and dry. Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular:  Regular rate and rhythm.  Lungs:  Clear.  Abdomen: Soft.
Foreign Body - Fingernail  ( General Medicine)
Description:  Foreign body of the left fifth fingernail (wooden splinter).  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.

HISTORY OF PRESENT ILLNESS:,  Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday.  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum."  Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed.  He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife.  ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES:  Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate.  It does not protrude beyond the end of the nail plate.  There is no active bleeding.  There is no edema or erythema of the digit tip.  Flexion and extension of the DIP joint is intact.  The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off.  In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain.  Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip.  I was able to grasp the splinter and remove this.  No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid.  If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.
Gen Med Consult - 15  ( General Medicine)
Description:  Complaint of mood swings and tearfulness.

HISTORY OF PRESENT ILLNESS:,  A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  This has been problematic over the last several months and is just worsening to the point where it is impairing her work.  Her boss asks her if she was actually on drugs in which she said no.  She stated may be she needed to be, meaning taking some medications.  The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  She has not been on any other antidepressants in the past.  She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  She denies any hot flashes or night sweats.  She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer.  The patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  She was recently treated for sinusitis.,ALLERGIES:,  She is allergic to Sulfa.,CURRENT MEDICATIONS:,  Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  Mood is dysthymic.  Affect is tearful.,Skin:  Without rash.,Eyes:  PERRLA.  Conjunctivae are clear.,Neck:  Supple with adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,ASSESSMENT:,1.  Postsurgical menopause.,2.  Mood swings.,PLAN:,  I spent about 30 minutes with the patient discussing treatment options.  I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  We will try starting her back on Wellbutrin XL 150 mg daily.  She may increase to 300 mg daily after three to seven days.  Samples provided initially.  If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  I also recommended increasing her exercise.  We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile.  Follow up here in two weeks or sooner if any other problems.  She is needing her annual breast exam as well.
Flank Pain - Consult - 1  ( General Medicine)
Description:  Left flank pain, ureteral stone.

REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.
Flank Pain - Consult  ( General Medicine)
Description:  Left flank pain and unable to urinate.

CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  Details are in the history and physical.  She does have a vague history of a bruised left kidney in a motor vehicle accident.  She feels much better today.  I was consulted by Dr. X.,MEDICATIONS:,  Ritalin 50 a day.,ALLERGIES: , To penicillin.,PAST MEDICAL HISTORY: , ADHD.,SOCIAL HISTORY:,  No smoking, alcohol, or drug abuse.,PHYSICAL EXAMINATION: , She is awake, alert, and quite comfortable.  Abdomen is benign.  She points to her left flank, where she was feeling the pain.,DIAGNOSTIC DATA: , Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,LABORATORY WORK: , Showed white count 6200, hematocrit 44.7.  Liver function tests and amylase were normal.  Urinalysis 3+ bacteria.,IMPRESSION:,1.  Left flank pain, question etiology.,2.  No evidence of surgical pathology.,3.  Rule out urinary tract infection.,PLAN:,1.  No further intervention from my point of view.,2.  Agree with discharge and followup as an outpatient.  Further intervention will depend on how she does clinically.  She fully understood and agreed.
Female ROS  ( General Medicine)
Description:  Sample female review of systems.

FEMALE REVIEW OF SYSTEMS:,Constitutional:  Patient denies fevers, chills, sweats and weight changes.,Eyes:  Patient denies any visual symptoms.,Ears, Nose, and Throat:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,Cardiovascular:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,Respiratory:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No dysuria, frequency or incontinence.  No difficulties with vaginal discharge.,Musculoskeletal:  No myalgias or arthralgias.,Breasts:  Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge.,Neurologic:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,Psychiatric:  Patient denies problems with mood disturbance.  No problems with anxiety.,Endocrine:  No excessive urination or excessive thirst.,Dermatologic:  Patient denies any rashes or skin changes.
Gen Med Consult - 11  ( General Medicine)
Description:  Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).

CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she "wants to.",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.
Gen Med Consult - 13  ( General Medicine)
Description:  Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.

SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.