smoh/medical-transcriptions huggingface dataset:
Cholecystitis - Discharge Summary  ( Discharge Summary)
Description:  Cholecystitis with choledocholithiasis.   Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.

REASON FOR ADMISSION: , Cholecystitis with choledocholithiasis.,DISCHARGE DIAGNOSES: , Cholecystitis, choledocholithiasis.,ADDITIONAL DIAGNOSES,1.  Status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2.  Laparoscopic paraventral hernia in 11/07.,3.  History of sleep apnea with reversal after 100-pound weight loss.,4.  Morbid obesity with bmi of 39.4.,PRINCIPAL PROCEDURE:,  Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,HOSPITAL COURSE: , The patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone.  She was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct.  She subsequently went for a HIDA scan to rule out cholecystitis.  Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage.  She was taken to the operating room that night for laparoscopic cholecystectomy.  We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast.  It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone.  The patient had undergone a Roux-en-Y gastric bypass but could not receive an ERCP and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted.  This necessitated conversion to an open operation.  She was transferred to the medical surgical unit postoperatively.  She had a significant amount of incisional pain following morning, but no nausea.  A Jackson-Pratt drain, which was left in place in two places showed serosanguineous fluid.  White blood cell count was down to 7500 and bilirubin decreased to 2.1.  Next morning she was started on a liquid diet.  Foley catheter was discontinued.  There was no evidence of bile leak from the drains.  She was advanced to a regular diet on postoperative day #3, which was 12/09/07.  The following morning she was tolerating regular diet.  Her bowels had begun to function, and she was afebrile with her pain control with oral pain medications.  Jackson-Pratt drain was discontinued from the wound.  The remaining Jackson-Pratt drain was left adjacent to her cystic duct.  Following morning, her laboratory studies were better.  Her bilirubin was down to normal and white blood cell count was normal with an H&H of 9 and 26.3.  Jackson-Pratt drain was discontinued, and she was discharged home.  Followup was in 3 days for staple removal.  She was given iron 325 mg p.o. t.i.d. and Lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain.
COPD - Discharge Summary  ( Discharge Summary)
Description:  A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.

HISTORY OF PRESENT ILLNESS:  ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD.  Unfortunately over the past few months he has returned to pipe smoking.  At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy.  COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click.  Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES:  ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7.  Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol.  The patient improved on this regimen.  Chest x-ray did not show any CHF.  The cortisone was tapered.  The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES:  ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  To follow up with me in the office in 4-5 days.
D&C - Discharge Summary  ( Discharge Summary)
Description:  Hysteroscopy, dilatation and curettage (D&C), and myomectomy.  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,OPERATIONS PERFORMED:,1.  Hysteroscopy.,2.  Dilatation and curettage (D&C).,3.  Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed.  Hysteroscopy revealed a large endometrial cavity fibroid.  Careful shaving and excision of this fibroid was performed with removal of the fibroid.  Hemostasis was noted completely at the end of this procedure.  Postoperatively, the patient has done well.  The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  The patient is now ambulating without difficulty and tolerating her diet.  The patient desires to go home.  The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:  ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  Ambulate with assistance at home only.  The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care.  The patient was given full and complete postop and discharge instructions.  All her questions were answered.
COPD & Bronchitis - Discharge Summary  ( Discharge Summary)
Description:  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.

DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.
CHF & Pleural Effusion - Discharge Summary  ( Discharge Summary)
Description:  Congestive heart failure (CHF) with left pleural effusion.  Anemia of chronic disease.

DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1.  Congestive heart failure (CHF) with pleural effusion.,2.  Hypertension.,3.  Prostate cancer.,4.  Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix.  He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con.  Chest x-rays were followed.  He did have free flowing fluid in his left chest.  Radiology consultation was obtained for thoracentesis.  The patient was seen by Dr. Y. An echocardiogram was done.  This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3.  An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia.  Cardiac enzymes were negative.  Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued.  The patient felt much better after the thoracentesis.  I do not have the details of this, i.e., the volumes.  No fluid was sent for routine studies.,LABORATORY AT DISCHARGE: , Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0.  Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams.  Magnesium was 1.8, calcium was 8.1.  Liver enzymes were unremarkable.  Cardiac enzymes were normal as mentioned.  PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift.  This was presumed due to the corticosteroids.  H&H was 32.3/11.3 and platelets 352,000, and MCV was 99.  The patient's O2 saturations on room air were normal.,Vital signs were stable.,DISCHARGE MEDICATIONS: , He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.,FOLLOWUP: , He will be followed in my office in 1 week.  He is to notify if recurrent fever or chills.,PROGNOSIS:  ,Guarded.
Cellulitis - Discharge Summary  ( Discharge Summary)
Description:  Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. 

DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.
Back & Leg Pain - Discharge Summary  ( Discharge Summary)
Description:  Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.  Chronic pain syndrome.

ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted
Chest Pain & Respiratory Insufficiency  ( Discharge Summary)
Description:  A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina.

We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.
BRCA-2 mutation  ( Discharge Summary)
Description:  Discharge summary of a patient with a BRCA-2 mutation.

DISCHARGE DIAGNOSES:,  BRCA-2 mutation.  ,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old with a BRCA-2 mutation.  Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION:  ,The chest was clear.  The abdomen was nontender.  Pelvic examination shows no masses.  No heart murmur.  ,HOSPITAL COURSE:  ,The patient underwent surgery on the day of admission.  In the postoperative course she was afebrile and unremarkable.  The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN:  ,The patient will remain at rest initially with progressive ambulation after.  She will avoid lifting, driving or intercourse.  She will call me if any fevers, drainage, bleeding, or pain.  Follow up in my office in four weeks.  Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain.
Cardiac Transfer Summary  ( Discharge Summary)
Description:  Need for cardiac catheterization.  Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity,  a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.

REASON FOR TRANSFER:,  Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1.  Coronary artery disease.,2.  Chest pain.,3.  History of diabetes.,4.  History of hypertension.,5.  History of obesity.,6.  A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7.  Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1.  Echocardiogram.,2.  MRI of the brain.,3.  Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details.  In brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  He was brought in by a friend.  The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  His vital signs were stable on admission.  He was ruled out for myocardial infarction with troponin x2.  An echocardiogram showed concentric LVH with an EF of 62%.  I had Cardiology come to see the patient, who reviewed the records from Fountain Valley.  Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax.  I performed an MRI, which showed a 1 cm lesion in the right parietal lobe.  I was going to call Neurology at XYZ for evaluation.  However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:,  Stable.,DISCHARGE MEDICATIONS:,1.  Aspirin 325 mg p.o. daily.,2.  Lovenox 40 mg p.o. daily.,3.  Regular Insulin sliding scale.,4.  Novolin 70/30, 15 units b.i.d.,5.  Metformin 500 mg p.o. daily.,6.  Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.
Dietary Consult - 4  ( Diets and Nutritions)
Description:  Counting calorie points, exercising pretty regularly, seems to be doing well

SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.
Anterior Cervical Discectomy & Fusion - Discharge Summary  ( Discharge Summary)
Description:  Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches."  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.