smoh/medical-transcriptions huggingface dataset:
Cardiac Consultation - 2  ( Consult - History and Phy.)
Description:  To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,
Cancer of the nasopharynx  ( Consult - History and Phy.)
Description:  T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.

DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles  carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:,  0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well.  He is working.  He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics.  Overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs:  Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT:  Extraocular muscles intact.  Sclerae not icteric.  Oral cavity free of exudate or ulceration.  Dry mouth noted.,Lymph:  No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs:  Clear.,Cardiac:  Rhythm regular.,Abdomen:  Soft, nondistended.  Neither liver, spleen, nor other masses palpable.,Lower Extremities:  Without edema.,Neurologic:  Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1.  This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal.  I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  He has made a good recovery.  We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up.  We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.
Carbohydrate Counting  ( Consult - History and Phy.)
Description:  Dietary consultation for carbohydrate counting for type I diabetes.

SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.
Cardiac Consultation - 1  ( Consult - History and Phy.)
Description:  To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.

CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.
Buttock Abscess  ( Consult - History and Phy.)
Description:  Left buttock abscess, status post incision and drainage.   Recommended some local wound care

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.
Burn - Consult  ( Consult - History and Phy.)
Description:  First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.
Bladder Tumor  ( Consult - History and Phy.)
Description:  Recurrent bladder tumor.  The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.

CHIEF COMPLAINT:,  Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.  The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006.  This was followed by bladder instillation of BCG.  At this time, the patient denies any voiding symptoms or hematuria.  The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health.  No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented.  Her lungs are clear.  Heart, regular sinus rhythm.  Back, no CVA tenderness.  Abdomen, soft and nontender.  No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.
Bariatric Consult - Surgical Weight Loss - 3  ( Consult - History and Phy.)
Description:  Evaluation for bariatric surgery.

PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke.  She denies any history of cancer.  She does have a history of hepatitis which I will need to further investigate.  She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal.  She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:,  She is a single mother of one adopted child.,FAMILY HISTORY:  ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family.  Her mother is alive.  Her father is deceased from alcohol.  She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female.  She does not appear to have any significant residual deficits from her stroke.  There may be slight left arm weakness.,ASSESSMENT/PLAN:,  We will have her undergo routine nutritional and psychosocial assessment.  I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss.  She is otherwise at increased risk for future complications given her history, and weight loss will be a good option.  We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.
Barium Swallow Study & Speech Evaluation - 1  ( Consult - History and Phy.)

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.
Bariatric Consult - Surgical Weight Loss - 2  ( Consult - History and Phy.)
Description:  Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.

PAST MEDICAL HISTORY:  ,She had a negative stress test four to five years ago.  She gets short of breath in walking about 30 steps.  She has had non-insulin dependent diabetes for about eight years now.  She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married.  She is an office manager for a gravel company.  Her spouse is also overweight.  She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time.  She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:,  Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:,  She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass.  ABC will be asking for a letter of medical necessity from XYZ.  She will also need an EKG and clearance for surgery.  She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.
Bariatric Consult - Surgical Weight Loss - 1  ( Consult - History and Phy.)
Description:  Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single.  She drinks alcohol once a week.  She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM:  ,This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear to auscultation bilaterally.  Cardiovascular is normal sinus rhythm.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN:  ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band.  ABC will be asking for a letter of medical necessity from Dr. XYZ.  She will also see my nutritionist and social worker and have an upper endoscopy.  Once this is completed, we will submit her to her insurance company for approval.