smoh/medical-transcriptions huggingface dataset:
BCCa Excision - Lower Lid  ( Hematology - Oncology)
Description:  Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.

PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.
Anemia & Leukemia Followup  ( Hematology - Oncology)
Description:  Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer.  The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.

CHIEF COMPLAINT:,1.  Chronic lymphocytic leukemia (CLL).,2.  Autoimmune hemolytic anemia.,3.  Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008.  He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.  He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day.  He comes in to clinic today for follow-up and complete blood count.  At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:,  Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES:  ,Vicodin.,REVIEW OF SYSTEMS:  ,The patient reports ulcer on his tongue and his lip.  He has been off of Valtrex for five days.  He is having some difficulty with his night vision with his left eye.  He has a known cataract.  He denies any fevers, chills, or night sweats.  He continues to have headaches.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
Aplastic Anemia Followup  ( Hematology - Oncology)
Description:  Aplastic anemia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone.

CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone on 03/30/10.  She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury.  Her cyclosporine level was 555.  It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital.  She was transfused 2 units of packed red blood cells while in the hospital.  Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:,  Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  GERD.,3.  Osteoarthritis.,4.  Status post tonsillectomy.,5.  Status post hysterectomy.,6.  Status post bilateral cataract surgery.,7.  Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY:  ,She has no tobacco use.  She has rare alcohol use.  She has three children and is a widow.  Her husband died after they were married only eight years.  She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:
Adrenalectomy & Umbilical Hernia Repair  ( Hematology - Oncology)
Description:  Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.

PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
URI - SOAP  ( General Medicine)
Description:  Sore throat - Upper respiratory infection.

SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.
Weight Loss Evaluation  ( General Medicine)
Description:  Patient with morbid obesity.

REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,
Trouble breathing  ( General Medicine)
Description:  Patient with worsening shortness of breath and cough.

CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.
3-Dimensional Simulation  ( Hematology - Oncology)
Description:  3-Dimensional Simulation.  This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.

3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.  This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects.  With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended.  The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized.  Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived.  Radiographs are taken and these films are approved by the physician.  Appropriate marks are placed on the patient's skin or on the  immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are performed through the targeted area.  The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images.  The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures.  This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features.  Appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised.  If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.
Trouble Breathing - H&P   ( General Medicine)
Description:  History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.

CHIEF COMPLAINT: , "I have had trouble breathing for the past 3 days",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days.  He also states that he has been coughing accompanying with low-grade type fever.  He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,PMH: , DM, HTN, COPD, CAD,PSH:  ,CABG, appendectomy, tonsillectomy,FH:,  Non-contributory,SOCH: , Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  He smokes 1 pack a day of Newport for 30 years and is a social drinker.  He denies any illicit drug use.,TRAVEL HISTORY: , Denies any recent travel overseas,ALLERGIES: , Denies any drug allergies,HOME MEDICATIONS:,  Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:,  Same as above,PHYSICAL EXAM:,Vital signs are:  Temp.  99.3 F / BP 138/92, Resp.  22, P 88,General:  Patient is in mild acute respiratory distress,HEENT:,Head:  Atraumatic, normocephalic,,Eyes:
Tongue Swelling  ( General Medicine)
Description:  A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.

REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.
Thrombocytopenia - SOAP Note  ( General Medicine)
Description:  Patient with immune thrombocytopenia

SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,
Sepsis - Consult  ( General Medicine)
Description:  Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.