smoh/medical-transcriptions huggingface dataset:
Gen Med SOAP - 4  ( SOAP / Chart / Progress Notes)
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 Progress Note - 2  ( SOAP / Chart / Progress Notes)
Description:  Sample progress note - Gen Med.

CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.
Gen Med Progress Note - 6  ( SOAP / Chart / Progress Notes)
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 - 7  ( SOAP / Chart / Progress Notes)
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 - 4  ( SOAP / Chart / Progress Notes)
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 - 13  ( SOAP / Chart / Progress Notes)
Description:  Sepsis due to urinary tract infection.

SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS:  Temperature is 95.4.  Highest temperature recorded over the past 24 hours is 102.1.,CHEST:  Examination of the chest is clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.  Right renal angle is tender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5.  Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000.  BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1.  Sepsis due to urinary tract infection.  Urine culture shows Escherichia coli, resistant to Levaquin.  We changed to doripenem.,2.  Urinary tract infection, we will treat with doripenem, change Foley catheter,3.  Hypotension.  Resolved, continue intravenous fluids.,4.  Ischemic cardiomyopathy.  No evidence of decompensation, we with monitor.,5.  Diabetes type 2.  Uncontrolled.  Continue insulin sliding scale.,6.  Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7.  History of coronary artery disease.  Troponin indeterminate.  Cardiologist intends no further workup.  Continue medical treatment.  Most likely troponin is secondary to impaired clearance.
Gen Med Progress Note - 12  ( SOAP / Chart / Progress Notes)
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.
Gen Med Progress Note - 3  ( SOAP / Chart / Progress Notes)
Description:  Sample progress note - Gen Med.

CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:,  A 70-year-old female who was diagnosed with diabetes mellitus last fall.  She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132.  She feels well.  She walks 1-2 miles most days.  If the weather is bad, they go to a local mall.  Otherwise they walk outside.  She does complain of some sinus congestion and drainage for the last several days.  She is up-to-date on her mammogram that she had at the Baylis Building.  She sees Dr. Cheng for her gynecological care.  She is a nonsmoker.  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools.  She has nocturia x 1.  Denies swelling in her ankles.  She checks her feet regularly., ,PAST MEDICAL HISTORY:,  Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt:  185 B/P: 142/70.  When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P:  84 and regular.,General: A 70-year-old female who does not appear to be in acute distress.  ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation.  The right TM is slightly dull.
Gen Med Progress Note - 1  ( SOAP / Chart / Progress Notes)
Description:  Sample progress note - Gen Med.

CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.
Foot Pain - SOAP  ( SOAP / Chart / Progress Notes)
Description:  Patient having foot pain.

SUBJECTIVE:,  This 32-year-old female comes in again still having not got a primary care physician.  She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect.  She says that Project Access is trying to find her a doctor.  She is not currently on Project Access, and so she is here to get something for the pain in her foot.  I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004.  She said she does not have a primary care physician.  She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers.  She has been in here multiple times for different kinds of pain.  This pain she is having is in her foot.  She had surgery on it, and she has plates and screws.  She said she was suppose to see Dr. XYZ about getting some of the hardware out of it.  The appointment was cancelled, and that is why she came here.  It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her.  She did not injure her foot in any way recently.  It is chronically painful.  Every time she does very much exercise it hurts more.  We have x-rayed it in the past.  She has some hardware there.  It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars.  On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  They are all old, and the surgery was done over a year ago.  She is walking with a very slight limp.  There is no redness.  No heat.  No swelling of the foot or the ankle.  It is mildly tender around the medial side of the foot just inferior to the medial malleolus.  It is not warm or red.,ASSESSMENT:,  Foot pain.,PLAN:,  She has been in here before.  She seems very pleasant.  Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill.  After she left, I got to thinking about it and looked into her record.  She has been in here multiple times for pain medicine.  She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago.  We called Dr. XYZ office.  Dr. XYZ nurse said that the patient did not have an appointment today.  She has an appointment on June 15, 2004, for a postop check.  They did not tell her they would not see her today because of insurance, so the patient was lying to me.  We will keep that in mind the next time she returns, because she will likely be back.  She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.
Gen Med Progress Note  ( SOAP / Chart / Progress Notes)
Description:  The patient states that he feels sick and weak.

SUBJECTIVE:,  The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL:  The patient looks tired.,HEENT:  Oral mucosa is dry.,CHEST:  Clear to auscultation.  He states that he has a mild cough, not productive.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES:  There is no swelling.,NEURO:  The patient is alert and oriented x 3.  Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  Glucose is in the low 100s.  Comprehensive metabolic panel is unremarkable.  UA is negative for infection.,ASSESSMENT AND PLAN:,1.  Fever of undetermined origin, probably viral since white count is normal.  Would continue current antibiotics empirically.,2.  Dehydration.  Hydrate the patient.,3.  Prostatic hypertrophy.  Urologist, Dr. X.,4.  DVT prophylaxis with subcutaneous heparin.
Fundoplication & Gastrostomy Followup  ( SOAP / Chart / Progress Notes)
Description:  Followup of laparoscopic fundoplication and gastrostomy.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.

REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.