smoh/medical-transcriptions huggingface dataset:
Gen Med SOAP - 5  ( General Medicine)
Description:  General Medicine SOAP note.  Patient with shoulder bursitis, pharyngitis, attention deficit disorder, 

S:,  The patient is here today with his mom for several complaints.  Number one, he has been having issues with his right shoulder.  Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder.  He has been having issues ever since.  He is having difficulties raising his arm over his head.  He does have some intermittent numbness in his fingers at night.  He is not taking any anti-inflammatories or pain relievers.  He is also complaining of a sore throat.  He did have some exposure to Strep and he has a long history of strep throat.  Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation.  He is also being seen for ADHD by Dr. B.  Adderall and Zoloft.  He takes these once a day.  He does notice when he does not take his medication.  He is doing well in school.  He is socializing well.  He is maintaining his weight and tolerating the medications.  However, he is having issues with anger control.  He realizes when he has anger outbursts that it is a problem.  His mom is concerned.  He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:,  Reviewed and unchanged.,O:,  VSS.  In general, patient is A&Ox3.  NAD.  Heart:  RRR.  Lungs:  CTA.  HEENT:  Unremarkable.  He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip.  Musculoskeletal:  Limited in range of motion, active on the right.  He stops at about 95 degrees.  No muscle weakness.  Neurovascularly intact.  Negative biceps tenderness.  Psych:  No suicidal, homicidal ideations.  Answering questions appropriately.  No hallucinations.
Gen Med SOAP - 8  ( General Medicine)
Description:  Patient today with multiple issues.  

SUBJECTIVE: , I am following the patient today for multiple issues.  He once again developed gross hematuria, which was unprovoked.  His Coumadin has been held.  The patient has known BPH and is on Flomax.  He is being treated with Coumadin because of atrial fibrillation and stroke.  This is the second time he has had significant gross hematuria this month.  He also fell about a week ago and is complaining of buttock pain and leg pain.  We did get x-rays of hips, knees, and ankles.  Clearly, he has significant degenerative disease in all these areas.  No fractures noted however.  He felt that the pain is pretty severe and particularly worse in the morning.  His sinuses are bothering him.  He wonders about getting some nasal saline spray.  We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  He is not in any apparent distress.  He is comfortable in a seated position.  I did not examine him further today.,ASSESSMENT AND PLAN:,1.  Hematuria.  Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH.  We will also obtain a repeat UA as he did describe to me some dysuria.  However, I do not think this would account for the gross hematuria.  He will be started on an aspirin 81 mg p.o. daily.,2.  For the pain we will try him on Lortab.  He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3.  We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4.  For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use.
Gen Med SOAP - 6  ( General Medicine)
Description:  Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain

SUBJECTIVE:,  The patient is in with several medical problems.  He complains his mouth being sore since last week and also some "trouble with my eyes."  He states that they feel "funny" but he is seeing okay.  He denies any more diarrhea or abdominal pain.  Bowels are working okay.  He denies nausea or diarrhea.  Eating is okay.  He is emptying his bladder okay.  He denies dysuria.  His back is hurting worse.  He complains of right shoulder pain and neck pain over the last week but denies any injury.  He reports that his cough is about the same.,CURRENT MEDICATIONS:,  Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General:  He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs:  His age is 66.  Temperature:  97.7.  Blood pressure:  134/80.  Pulse:  88.  Weight:  201 pounds.,HEENT:  Head was normocephalic.  Examination of the throat reveals it to be clear.  He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder.  Back has limited range of motion.  He is nontender to his back.  Deep tendon reflexes are 2+ bilaterally in lower extremities.  Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.  He has normal bowel sounds.,ASSESSMENT:,1.  Clostridium difficile enteritis, improved.,2.  Right shoulder pain.,3.  Chronic low back pain.,4.  Yeast thrush.,5.  Coronary artery disease.,6.  Urinary retention, which is doing better.,PLAN:,  I put him on Diflucan 200 mg daily for seven days.  We will have him stop his metronidazole little earlier at his request.  He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course.  I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.)  Recheck with me in two to three weeks.
Gen Med SOAP - 3  ( General Medicine)
Description:  General Medicine SOAP note.

S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.
Gen Med SOAP - 4  ( General Medicine)
Description:  General Medicine SOAP note.

S:,  ABC is in today for a followup of her atrial fibrillation.  They have misplaced the Cardizem.  She is not on this and her heart rate is up just a little bit today.  She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy.  She is very adamant that she wants to stop the Coumadin.  She is tired of blood draws.  We have had a difficult time getting her regulated.  No chest pains.  No shortness of breath.  She is moving around a little bit better.  Her arm does not hurt her.  Her back pain is improving as well.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple.  LUNGS are clear to auscultation.  HEART is irregularly irregular, mildly tachycardic.  ABDOMEN is soft and nontender.  EXTREMITIES:  No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.
Gen Med SOAP - 11  ( General Medicine)
Description:  The patient has recently had an admission for pneumonia with positive blood count.  She returned after vomiting and a probable seizure.

SUBJECTIVE:,  The patient has recently had an admission for pneumonia with positive blood count.  She was treated with IV antibiotics and p.o. antibiotics; she improved on that.  She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102.  She was found to have strep.  She was treated with penicillin and sent home.  She returned about 8 o'clock after vomiting and a probable seizure.  Temperature was 104.5; she was lethargic after that.  She had an LP, which was unremarkable.  She had blood cultures, which have not grown anything.  The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:,  She is alert, recovering from anesthesia.  Head, eyes, ears, nose and throat are unremarkable.  Chest is clear to auscultation and percussion.  Abdomen is soft.  Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift.  CSF glucose was 68, protein was 16, and there were no cells.  The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count.  I am going to observe her overnight.
Gen Med SOAP - 2  ( General Medicine)
Description:  Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.

SUBJECTIVE:,  Overall, she has been doing well.  Her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  Her fasting blood sugar today is 120 by our Accu-Chek.  She is exercising three times per week.  Review of systems is otherwise unremarkable. ,OBJECTIVE:,  Her blood pressure is 110/60.  Other vitals are stable.  HEENT:  Unremarkable.  Neck:  Unremarkable.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Unchanged.  Extremities:  Unchanged.  Neurologic:  Unchanged. ,ASSESSMENT:,  ,1.  NIDDM with improved control. ,2.  Hypertension. ,3.  Coronary artery disease status post coronary artery bypass graft. ,4.  Degenerative arthritis. ,5.  Hyperlipidemia. ,6.  Hyperuricemia. ,7.  Renal azotemia. ,8.  Anemia. ,9.  Fibroglandular breasts. ,PLAN:,  We will get follow-up labs today.  We will continue with current medications and treatment.  We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY.  The patient is advised to proceed with previous recommendations.  She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.
Gen Med SOAP - 10  ( General Medicine)
Description:  The patient has NG tube in place for decompression.

SUBJECTIVE: , The patient has NG tube in place for decompression.  She says she is feeling a bit better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Pulse is 58 and blood pressure is 110/56.,SKIN:  There is good skin turgor.,GENERAL:  She is not in acute distress.,CHEST:  Clear to auscultation.  There is good air movement bilaterally.,CARDIOVASCULAR:  First and second sounds are heard.  No murmurs appreciated.,ABDOMEN:  Less distended.  Bowel sounds are absent.,EXTREMITIES:  She has 3+ pedal swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA:,  White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000.  Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31.,ASSESSMENT AND PLAN:,1.  Small bowel obstruction/paralytic ileus, rule out obstipation.  Continue with less aggressive decompression.  Follow surgeon's recommendation.,2.  Pulmonary fibrosis, status post biopsy.  Manage as per pulmonologist.,3.  Leukocytosis, improving.  Continue current antibiotics.,4.  Bilateral pedal swelling.  Ultrasound of the lower extremity negative for DVT.,5.  Hyponatremia, improving.,6.  DVT prophylaxis.,7.  GI prophylaxis.
Gen Med SOAP - 1  ( General Medicine)
Description:  Sample progress note - Gen Med.

SUBJECTIVE:,
Gen Med Progress Note - 7  ( General Medicine)
Description:  Patient with a three-day history of emesis and a four-day history of diarrhea

SUBJECTIVE:,  The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea.  Apparently, his brother had similar symptoms.  They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened.  But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad.  The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days.  He has not had any emesis today.  He has urinated this morning.  His parents are both concerned because he had a fever of 103 last night.  Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis.  He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS:  ,None.,ALLERGIES:  ,He has no known drug allergies.,REVIEW OF SYSTEMS:,  Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General:  He is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  106/75.  Temperature:  99.  Pulse:  112.  Weight is 54 pounds.,HEENT:  His TMs are normal bilaterally.  Posterior pharynx is unremarkable.,Neck:  Without adenopathy or thyromegaly.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Benign.,Skin:  Turgor is intact.  His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos.  His platelet count on his CBC is 215.,ASSESSMENT:,  Viral gastroenteritis.,PLAN:,  The parents did point out to me a rash that he had on his buttock.  There were some small almost pinpoint erythematous patches of papules that have a scab on them.  I did not see any evidence of petechiae.  Therefore, I just reassured them that this is a viral gastroenteritis.  I recommended that they stop giving him juice and just go with the Gatorade and water.  He is to stay away from milk products until his diarrhea and stomach upset have calmed down.  We talked about BRAT diet and slowly advancing his diet as he tolerates.  They have used some Kaopectate, which did not really help with the diarrhea.  Otherwise follow up as needed.
Gen Med Progress Note - 6  ( General Medicine)
Description:  A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.

SUBJECTIVE:,  This 3-year-old male is brought by his mother with concerns about his eating.  He has become a very particular eater, and not eating very much in general.  However, her primary concern was he was vomiting sometimes after particular foods.  They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit.  After this occurred several times, they stopped giving him carrots.  Last week, he ate some celery and the same thing happened.  They had not given him any of that since.  He eats other foods without any apparent pain or vomiting.  Bowel movements are normal.  He does have a history of reactive airway disease, intermittently.  He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:,  He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight:  31.5 pounds, which is an increase of 2.5 pounds since May.  Temperature is 97.1.  He certainly appears in no distress.  He is quite interested in looking at his books.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Cardiac:  Regular rate and rhythm without murmurs.,Abdomen:  Soft without organomegaly, masses, or tenderness.,ASSESSMENT:,  Report of vomiting and abdominal pain after eating raw carrots and celery.  Etiology of this is unknown.,PLAN:,  I talked with mother about this.  Certainly, it does not suggest any kind of an allergic reaction, nor obstruction.  At this time, they will simply avoid those foods.  In the future, they may certainly try those again and see how he tolerates those.  I did encourage a wide variety of fruits and vegetables in his diet as a general principle.  If worsening symptoms, she is welcome to contact me again for reevaluation.
Gen Med Progress Note - 4  ( General Medicine)
Description:  The patient is in complaining of headaches and dizzy spells.

SUBJECTIVE:,  The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf.  She describes her dizziness as both vertigo and lightheadedness.  She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias.  She has noticed a few more bruises on her legs.  No fever or chills with slight cough.  She has had more chest pains but not at present.  She does have a little bit of nausea but no vomiting or diarrhea.  She complains of some left shoulder tenderness and discomfort.  She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:,  She is currently on her nystatin ointment to her lips q.i.d. p.r.n.  She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs.  Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General:  She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs:  Her age is 55.  Temperature:  98.2.  Blood pressure:  110/70.  Pulse:  72.  Weight:  174 pounds.,HEENT:  Head was normocephalic.  Throat:  Clear.  TMs clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted.  Her shoulders have full range of motion.  She has minimal tenderness to the left shoulder anteriorly.,Skin:  There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1.  Headaches.,2.  Dizziness.,3.  Atypical chest pains.,4.  Chronic renal failure.,5.  Type II diabetes.,6.  Myalgias.,7.  Severe anxiety (affect is still quite anxious.),PLAN:,  I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m.  I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin.  Recheck in one week.  I think her dizziness is multifactorial and due to enlarged part of her anxiety.  I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin.
Gen Med Progress Note - 12  ( General Medicine)
Description:  Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.

SUBJECTIVE: , The patient was seen and examined.  He feels much better today, improved weakness and decreased muscular pain.  No other complaints.,PHYSICAL EXAMINATION:,GENERAL:  Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS:  Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT:  NC/T, PERRLA, EOMI.,NECK:  Supple.,HEART: Regular rate and rhythm.,RESPIRATORY:  Clear bilateral.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3.  CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1.  Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  Continue IV fluids.  We will monitor.,2.  Acute on chronic renal failure.  We will follow up with Nephrology recommendation.,3.  Anemia, drop in hemoglobin most likely hemodilutional.  Repeat CBC in a.m.,4.  Leukocytosis, improving.,5.  Elevated liver enzyme, most likely secondary to rhabdomyolysis.  The patient denies any abdominal pain and ultrasound is unremarkable.,6.  Hypertension.  Blood pressure controlled.,7.  Elevated cardiac enzyme, follow up with Cardiology recommendation.,8.  Obesity.,9.  Deep venous thrombosis prophylaxis.  Continue Lovenox 40 mg subcu daily.