smoh/medical-transcriptions huggingface dataset:
Discharge Summary - Hip Surgery  ( Discharge Summary)
Description:  A 47-year-old female with a posttraumatic AV in the right femoral head.

ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.
Discharge Summary - Cholelithiasis  ( Discharge Summary)
Description:  Patient with complaint of symptomatic cholelithiasis.

ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:,  Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:,  None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis.  She was afebrile.  She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure.  She tolerated without difficulty.  She had her pain controlled with p.o. pain medicine.  She was afebrile.  She is tolerating liquid diet.  It was felt that the patient is stable for discharge.  She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs.  We will check a UA and urine culture prior to discharge.  I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain.  Her labs were within normal limits.  She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related.  Her labs in terms of her bilirubin were within normal limits.  Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed.  They were 51 and 83 for the AST and ALT respectively.  I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower.  She needs to keep her wound clean and dry.  She is not to engage in any heavy lifting greater than 10 pounds x2 weeks.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility.  She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:,  We will follow up on both urinalysis and cultures.  She is instructed to follow up with Dr. X in 2 weeks.  She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.
Discharge Summary - Cerebral Palsy  ( Discharge Summary)
Description:   a pleasant 62-year-old male with cerebral palsy

DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.
Discharge Summary - 3  ( Discharge Summary)
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 - 2  ( Discharge Summary)
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 - 5  ( Discharge Summary)
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 - 12  ( Discharge Summary)
Description:  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.

CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.
Discharge Summary - 15  ( Discharge Summary)
Description:  Gastroenteritis and autism.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. 

FINAL DIAGNOSES:,1.  Gastroenteritis.,2.  Autism.,DIET ON DISCHARGE:,  Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.  She developed vomiting 3 days prior to admission, but did not have diarrhea.  She voided on the day of admission.  When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight.  She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA:  ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64.  Chest x-ray and abdominal films were unremarkable.  Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800.  Urinalysis was negative for ketones.  Specific gravity 1.023, and negative for protein.  Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118.  Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE:  ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated.  On the second hospital day, mother was comfortable taking her to home.  Mother did not have a good explanation for the weight loss.  In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94.  Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge.  We will follow up in the office and try to further evaluate her for the unexplained weight loss.  She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss.  The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.
Discharge Summary - 11  ( Discharge Summary)
Description:  Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.

ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC is a 57-year-old woman.  She suffers from morbid obesity.  She also has diabetes and obstructive sleep apnea.  She was evaluated in the Bariatric Surgical Center for placement of a band.  During her workup, she was noted to have evidence of cholelithiasis.  It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band.  The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438.  She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital.  She was seen by Dr. A.  He put her on an insulin drip.  Her sugars slowly did come down to normal down to between 115 and 134.  On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy.  She was noted to be a difficult intubation for the procedure.  There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder.  She underwent the procedure.  She tolerated without difficulty.  She was recovered in the Postoperative Care Unit and then returned to the floor.  Her blood sugar postprocedure was noted to be 233.  She was started back on a sliding scale insulin.  She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS:  ,To return to the Medifast diet.  To continue with her blood glucose.  She needs to follow up with Dr. B, and she will see me next week on Friday.  We will determine if we will proceed with her lap band at that time.  She may shower.  She needs to keep her wounds clean and dry.  No heavy lifting.  No driving on narcotic pain medicines.  She needs to continue with her CPAP machine and continue to monitor her sugars.
Discharge Summary - 13  ( Discharge Summary)
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.