smoh/medical-transcriptions huggingface dataset:
End Stage Renal Disease - Consult  ( Consult - History and Phy.)
Description:  Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night.  He took some nitroglycerin tablets at home with no relief.  He came to the ER.  He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock.  This is a late entry dictation.  Presently lying in bed, but he feels fine.  Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea.  Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1.  Coronary artery disease, status post stent placement two years ago.,2.  Diabetes mellitus for the last 12 years.,3.  Hypertension.,4.  End-stage renal disease.,5.  History of TIA in the past.,PAST SURGICAL HISTORY:,1.  As mentioned above.,2.  Cholecystectomy.,3.  Appendectomy.,4.  Right IJ PermaCath placement.,5.  AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:,  He smoked 2 to 3 packets per day for at least last 10 years.  He quit smoking roughly about 20 years ago.  Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES:  ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL:  He is alert, seems to be in no apparent distress.,VITAL SIGNS:  Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT:  Atraumatic and normocephalic.,NECK:  No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation.  Air entry bilateral equal.,HEART:  S1 and S2.  No pericardial rub.,ABDOMEN:  Soft and nontender.  Normal bowel sounds.,EXTREMITIES:  No edema.,NEUROLOGIC:  The patient is alert without focal deficit.,LABORATORY DATA:,  Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1.  End-stage renal disease, plan for dialysis today.,2.  Diabetes mellitus.,3.  Chest pain for coronary angiogram today.,4.  Hypertension, blood pressure stable.,PLAN: , Currently follow the patient.  Dr. Z is going to assume the care.
Encephalopathy  - Rehab Consult   ( Consult - History and Phy.)
Description:  Encephalopathy related to normal-pressure hydrocephalus.

ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,
ENT Consult - 1  ( Consult - History and Phy.)
Description:  Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.

CHIEF COMPLAINT: , Chronic otitis media, adenoid hypertrophy.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions.  He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy.  He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes.,ALLERGIES:  ,None.,MEDICATIONS:,  Antibiotics p.r.n.,FAMILY HISTORY: , Diabetes, heart disease, hearing loss, allergy and cancer.,MEDICAL HISTORY: , Unremarkable.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Some minor second-hand tobacco exposure.  There are no pets in the home.,PHYSICAL EXAMINATION:,  Ears are well retracted, immobile.  Tympanic membranes with effusions present bilaterally.  No severe congestions, thick mucoid secretions, no airflow.  Oral cavity:  Oropharynx 2 to 3+ tonsils.  No exudates.  Floor of mouth and tongue are normal.  Larynx and pharynx not examined.  Neck:  No nodes, masses or thyromegaly.  Lungs:  Reveal rare rhonchi, otherwise, clear.  Cardiac exam:  Regular rate and rhythm.  No murmurs.  Abdomen:  Soft, nontender.  Positive bowel sounds.  Neurologic exam:  Nonfocal.,IMPRESSION:  ,Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.,PLAN: , The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.
Elevated BNP - Consult  ( Consult - History and Phy.)
Description:  Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.

REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.
Dural AVM  ( Consult - History and Phy.)
Description:  Patient with episode of lightheadedness and suddenly experienced vertigo.

CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.
Ear Pain - Drainage  ( Consult - History and Phy.)
Description:  Right ear pain with drainage - otitis media and otorrhea.

CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.
Discoid Lupus  ( Consult - History and Phy.)
Description:  A 12-year-old with discoid lupus on the control with optimal regimen.

HISTORY:  ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit.  She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus.  A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again.  She has been using her cream, which is hydrocortisone at night and applying it with no problems.  She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight.  She denies any ulcerations in her mouth, eye problems, or any lumps in her body.  She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL:  She is alert, active, and oriented in no distress.,HEENT:  She had a head full of hair with no bald spots.  She has a macular rash on her cheeks bilaterally with hyperpigmented circles.  No scales, no excoriations, and no palpable erythema.  Oral mucosa is clear with no ulcerations.,NECK:  Soft with no masses.  She does have acanthosis nigricans on the base of the neck.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft and nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation, swelling, or tenderness in any of her joints.,SKIN:  Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented.  No erythema, no purpura, no petechiae, and no raised borders.  They look more like cigarette points.  She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light.  She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:,  Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities.  Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen.  We are going to switch her to Protopic at night, especially in the face.  Continue on Plaquenil, get some laboratories and wait for the results.  Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up.  Future plans will be depending on whether or not she evolves into a full-blown lupus.  I discussed the plan with her mother and they had no further questions.
Dietary Consultation - 2  ( Consult - History and Phy.)
Description:  Dietary consultation for weight reduction secondary to diabetes.

SUBJECTIVE:,  This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes.  She did attend diabetes education classes at Abc Clinic.  She comes however, wanting to really work at weight reduction.  She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds.  She is now following a veggie diet which she learned about in Poland originally.  She has been on it for three weeks and intends to follow it for another three weeks.  This does not allow any fruits or grains or starchy vegetables or meats.  She does eat nuts for protein.  She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet.  She also wants to know that if she gets skinny enough, if the diabetes will go away.  Her problem time, blood sugar wise, is in the morning.  She states that if she eats too much in the evening that her blood sugars are always higher the next morning.,OBJECTIVE:,  Weight:  189 pounds.  Reported height:  5 feet 5 inches.  BMI is approximately 31-1/2.  Diabetes medications include metformin 500 mg daily.  Lab from 5/12/04:  Hemoglobin A1C was 6.4%.,A diet history was obtained.  I instructed the patient on dietary guidelines for weight reduction.  A 1200-calorie meal plan was recommended.,ASSESSMENT:,  Patient's diet history reflects that she is highly restricting carbohydrates in her food intake.  She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning.  This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts.  She is doing some physical activity two to three times a week.  This includes aerobic walking with weights on her arms and her ankles.  She is likely going to need to increase frequency in this area to help support weight reduction.  Her basal metabolic rate was estimated at 1415 calories a day.  Her total calorie requirements for weight maintenance are estimated at 1881 calories a day.  A 1200-calorie meal plan should support a weight loss of at least one pound a week.,PLAN:,  Recommend patient increase the frequency of her walking to five days a week.  Encouraged a 30-minute duration.  Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations.  And lastly, I encouraged caloric intake of just under 1200 calories daily.  Recommend keeping food records and tracking caloric intake.  It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage.  However, I encouraged her to be careful not to reduce calories below 1000 calories daily.  She may want to consider a multivitamin as well.  This was a one-hour consultation.
Dietary Consultation - 1  ( Consult - History and Phy.)
Description:  Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.

SUBJECTIVE:,  This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia.  The patient reports that she has resumed food record keeping which she feels like it has given her greater control.  Her physical activity level has remained high.  Her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.,OBJECTIVE:, Vital Signs:  Weight is 189-1/2 pounds.  Food records were reviewed,ASSESSMENT:,  The patient has experienced a weight loss of 1-1/2 pounds in the last month.  She is commended for these efforts.  We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks.  We discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping.  We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis.  We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms.  This will likely be around 2:30 or 3 p.m. for her.  We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.,PLAN:,  I recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m.  It will be helpful if this snack includes some protein such as nuts or low-fat cheese.  She is also encouraged to continue with her record keeping for food choices and calorie points.  I also recommended she maintain her high level of physical activity.  Will plan to follow the patient in one month for ongoing support.  This was a 30-minute consultation.