smoh/medical-transcriptions huggingface dataset:
Female Exam & ROS  ( General Medicine)
Description:  Sample female exam and review of systems.

GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vitals:  Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  Bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Breasts:  Bilaterally symmetrical without tenderness, masses.  No axillary tenderness or masses.,Pelvic examination:  Revealed normal external genitalia.  Pap smear obtained without difficulty.  Bimanual examination revealed no pelvic tenderness or masses.  No uterine enlargement.  Rectal examination revealed normal sphincter tone, no rectal masses.  Stool is Hemoccult negative.
Female Physical Exam - 2  ( General Medicine)
Description:  Sample female physical exam.

FEMALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,Neck:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,Abdomen:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Reveals normal female external genitalia.  Speculum exam reveals vaginal mucosa to be pink and rugous.  Cervix appears normal.  Bimanual exam reveals uterus to be within normal limits.  Adnexa are normal without masses appreciated.  There is no cervical motion tenderness.,Rectal Exam:  Normal rectal tone.  No masses are appreciated.  Hemoccult is negative.,Extremities:  Reveal no clubbing, cyanosis, or edema.,Joint Exam:  Reveals no tenosynovitis.,Integumentary:  Normal breast tissue without lumps or masses.  There are no skin changes over the breasts.  Axillae are free of masses.,Neurologic:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,Psychiatric:  Grossly normal.,Dermatologic:  No lesions or rashes.
Fifth Disease - SOAP  ( General Medicine)
Description:  Fifth disease with sinusitis

SUBJECTIVE:,  Grandfather brings the patient in today because of headaches, mostly in her face.  She is feeling pressure there with a lot of sniffles.  Last night, she complained of sore throat and a loose cough.  Over the last three days, she has had a rash on her face, back and arms.  A lot of fifth disease at school.  She says it itches and they have been doing some Benadryl for this.  She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:,  Asthma and allergies.,FAMILY HISTORY:  ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General:  The patient is an 11-year-old female.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color and good light reflex.  Oropharynx is pink and moist.  No erythema or exudates.  She has postnasal discharge.  Nares are swollen and red.  Purulent discharge in the posterior turbinates.  Both maxillary sinuses are tender.  She has some mild tenderness in the left frontal sinus.  Eyes are puffy and she has dark circles.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink.  Moist mucous membranes.  Red, lacey rash from the wrists to the elbows, both sides.  It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:,  Fifth disease with sinusitis.,PLAN:,  Omnicef 300 mg daily for 10 days.  May use some Zyrtec for the itching.  Samples are given.
Down's syndrome  ( General Medicine)
Description:  A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.

SUBJECTIVE:,  This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis.  He has finished six weeks of Lamisil without any problems.  He is due to have an ALT check today.  At his appointment in April, I also found that he was hypothyroid with elevated TSH.  He was started on Levothroid 0.1 mg and has been taking that daily.  We will recheck a TSH today as well.  His mother notes that although he does not like to take the medications, he is taking it with encouragement.  His only other medications are some eyedrops for his cornea.,OBJECTIVE:,  Weight was 149 pounds, which is up 2 pounds.  Blood pressure was 120/80.  Pulse is 80 and regular.,Neck:  Supple without adenopathy.  No thyromegaly or nodules were palpable.,Cardiac:  Regular rate and rhythm without murmurs.,Skin:  Examination of the toenails showed really no change yet.  They are still quite thickened and yellowed.,ASSESSMENT:,1.  Down’s syndrome.,2.  Onychomycosis.,3.  Hypothyroidism.,PLAN:,1.  Recheck ALT and TSH today and call results.,2.  Lamisil 250 mg #30 one p.o. daily with one refill.  They will complete the next eight weeks of therapy as long as the ALT is normal.  I again reviewed the symptoms of liver dysfunction.,3.  Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.
Fall & Laceration  ( General Medicine)
Description:  Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.

CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.
ER Report - URI  ( General Medicine)
Description:  Patient in ER with upper respiratory infection

HISTORY OF PRESENT ILLNESS:,  The patient is a two-and-a-half-month-old male who has been sick for the past three to four days.  His mother has described congested sounds with cough and decreased appetite.  He has had no fever.  He has had no rhinorrhea.  Nobody else at home is currently ill.  He has no cigarette smoke exposure.  She brought him to the emergency room this morning after a bad coughing spell.  He did not have any apnea during this episode.,PAST MEDICAL HISTORY:,  Unremarkable.  He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL:  Sleeping, easily aroused, smiling, and in no distress.,HEENT:  Soft anterior fontanelle.  TMs are normal.  Moist mucous membranes.,LUNGS:  Equal and clear.,CHEST:  Without retraction.,HEART:  Regular in rate and rhythm without murmur.,ABDOMEN:  Benign.,DIAGNOSTIC STUDIES:,  Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:,  Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares.  Smaller but more frequent feeds.  Discuss proper sleeping position.  Recheck if there is any fever or if he is no better in the next three days.
Discharge Summary - 5  ( General Medicine)
Description:  A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.

DATE OF ADMISSION:,  MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:,  X Y, M.D.,ADMITTING DIAGNOSES:,1.  Ewing sarcoma.,2.  Anemia.,3.  Hypertension.,4.  Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION:  ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY.  A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation.  MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction.  CT showed similar result.  The patient received her first cycle of chemotherapy on MM/DD/YYYY.  On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy.  She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1.  Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.
Discharge Summary - 2  ( General Medicine)
Description:  Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.

ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting.
Discharge Summary - 3  ( General Medicine)
Description:  Patient with increased shortness of breath of one day duration.

DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required.
Discharge Summary - 13  ( General Medicine)
Description:  Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.

ADMITTING DIAGNOSES:,1.  Bradycardia.,2.  Dizziness.,3.  Diabetes.,4.  Hypertension.,5.  Abdominal pain.,DISCHARGE DIAGNOSIS:,  Sick sinus syndrome.  The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patient was admitted to the intensive care unit.  Dr. X was consulted.  A temporary intracardiac pacemaker was placed.  Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings.  The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission.  This was considered to be a sick sinus syndrome.  Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement.  This is a Medtronic pacemaker.  After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled.  Right femoral artery catheter was removed.  The patient remained with good pulses in the right lower extremity with no hematoma.  Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90.  Medication was adjusted to benazepril 20 mg a day.  Norvasc 5 mg was added as well.  Her blood pressure has remained better, being today 144/74 and 129/76.,FINAL DIAGNOSES:  ,Sick sinus syndrome.  The rest of her past medical history remained without change, which are:,1.  Diabetes mellitus.,2.  History of peptic ulcer disease.,3.  Hypertension.,4.  Insomnia.,5.  Osteoarthritis.,PLAN: , The patient is discharged home to continue her previous home medications, which are:,1.  Actos 45 mg a day.,2.  Bisacodyl 10 mg p.o. daily p.r.n. constipation.,3.  Cosopt eye drops, 1 drop in each eye 2 times a day.,4.  Famotidine 20 mg 1 tablet p.o. b.i.d.,5.  Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6.  Lotensin (benazepril) increased to 20 mg a day.,7.  Triazolam 0.125 mg p.o. at bedtime.,8.  Milk of Magnesia suspension 30 mL daily for constipation.,9.  Tylenol No.  3, one to two tablets every 6 hours p.r.n. pain.,10.  Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.,11.  Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12.  The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement.,DISCHARGE INSTRUCTIONS: , Follow up in the office in 10 days for staple removal.  Resume home activities as tolerated with no starch, sugar-free diet.
Discharge Summary - 16  ( General Medicine)
Description:  Upper respiratory illness with apnea, possible pertussis.  a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, and questionable fever.

ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, questionable fever, but only 99.7.  Their usual doctor prescribed amoxicillin over the phone.  The coughing persisted and worsened.  She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells.  They did witness some apnea.  They gave some Rocephin, did some labs, and the patient was transferred to hospital.,PHYSICAL EXAMINATION: , On admission, GENERAL:  Well-developed, well-nourished baby in no apparent distress. HEENT:  There was some nasal discharge.  Remainder of the HEENT was normal.  LUNG:  Had few rhonchi.  No retractions.  No significant coughing or apnea during the admission physical.  ABDOMEN:  Benign.  EXTREMITIES:  Were without any cyanosis.,SIGNIFICANT LABS AND X-RAYS:  ,She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP.  An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate.  Well at hospital, she had a rapid influenza swab done, which was negative.  She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative.  She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart.  I do know that the pertussis culture proved to be negative.,CONSULTATION: , Public Health Department was notified of a case of suspected pertussis.,HOSPITAL COURSE: , The baby was afebrile.  Required no oxygen in the hospital.  Actually fed reasonably well.  Did have one episode of coughing with slight emesis.  Appeared basically quite well between episodes.  Had no apnea witnessed and after overnight observation, the parents were anxious to go home.  The patient was started on Zithromax in the hospital.,CONDITION AND TREATMENT: , The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.,INSTRUCTIONS TO PATIENT:,  Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.