smoh/medical-transcriptions huggingface dataset:
Psych Consult - Psychosis   ( Psychiatry / Psychology)
Description:  Patient with a history of PTSD, depression, and substance abuse.

IDENTIFYING DATA:,  Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker.  Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior.  She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior.  Recently, she was picked up by Kent Police Department "leaping on Highway 99.",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY:  ,Unknown.,ALLERGIES:,  Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:,  Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit.  General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2.  Previous urine tox was positive for THC.  Urinalysis was negative, but did note positive UA wbc's.  CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I:  Psychosis.  Inpatient Psychiatric Team to follow.,AXIS II:  Deferred.,AXIS III:  We were unable to perform physical examination on the patient today secondary to her being in seclusion.  Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI.  We will wait until the patient is out of seclusion to perform examination.  Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy.  We will followup with the patient should any new medical issues arise.
Psych Consult - Psychosis - 1  ( Psychiatry / Psychology)
Description:  The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.

IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.  It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:,  Prior to admission, we do not have that information.  He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY:  ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude:  The patient is unresponsive.,Appearance:  He is lying in bed in the fetal position with a blanket over his head.,Psychomotor:  Catatonic.,EPS/TD:  Unable to assess though his limbs are quite contracted.,Affect:  Unresponsive.,Mood:  Unresponsive.,Speech:  Unresponsive.,Thought Process And Thought Content:  Unresponsive.,Psychosis:  Unable to elicit information to make this assessment.,Suicidal/Homicidal:  Also unable to elicit this information.,Cognitive Assessment:  Unable to elicit.,Judgment And Insight:  Unable to elicit.,Assets:  The patient is young.,Limitations:  Severe decompensation.,FORMULATION:  ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I:  Psychosis, NOS.,AXIS II:  Deferred.,AXIS III:  Dehydration.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1.  Stabilize medically from the dehydration per internal medicine.,2.  Medications, milieu therapy to assist with re-compensation.
Psych Consult - Bipolar Affective Disorder  ( Psychiatry / Psychology)
Description:  A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.

IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.
Mental Status Changes - Consult  ( Psychiatry / Psychology)
Description:  Mental status changes after a fall.  She sustained a concussion with postconcussive symptoms and syndrome that has resolved. 

CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's.  Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes.  She was very confused, incomprehensible speech, and was not responding appropriately.  She was transported here stable, with no significant changes.  She ultimately upon arrival here was unchanged in that she was not responding appropriately.  She would have garbled speech, somewhat inappropriate at times, and unable to follow commands.  No other history was able to be obtained.  All pertinent history is documented within the records.  Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT:  Without any obvious signs of trauma.  Pupils are equal and reactive.  Extraocular movements are difficult to assess with her eyes closed, but she will open to voice.  TMs, canals are normal without any signs of hemotympanum.  Nasal mucosa and oropharynx are normal.,NECK:  Nontender, full range of motion, was not examined initially, a collar was placed.,HEART:  Regular.,LUNGS:  Clear.,CHEST/BACK/ABDOMEN:  Without trauma.,SKIN:  With multiple excoriations from scratching and itching.,NEUROLOGIC:  Otherwise she has good sensation, withdrawals to pain.  When lifting the arm, she will hold them up and draw, let them down slowly.  With movement of the legs, she did straighten them back out slowly.  DTRs were intact and equal bilaterally.  Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine.  She has a history of being on Coumadin.  Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands.  CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved.  It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved.  At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation.  I have discussed this with her son, he agrees.  Otherwise, she has improved significantly.  The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.
Neurobehavioral Assessment  ( Psychiatry / Psychology)
Description:  Bender-Gestalt Neurological Battery and Beck testing.

BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation:  18,SUMMARY:,  The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately negative expectancies regarding his future and is expressing suicidal ideation. Great care should be taken to confirm the accuracy of the results as the patients seems over-medicated and/or drunk.
Falls - Discharge Summary  ( Psychiatry / Psychology)
Description:  Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.

CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for "attention."  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she "tripped" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.
Tinea Pedis - H&P  ( Podiatry)
Description:  Itchy red rash on feet - Tinea Pedis

CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes
Three Views - Foot  ( Podiatry)
Description:  Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.  

EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.
Asperger Disorder  ( Psychiatry / Psychology)
Description:  School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.   Asperger disorder.  Obsessive compulsive disorder.

SUBJECTIVE:  ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  He appears confused and depressed at times.  Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  He will attend social skills program in the summer.  ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  There is lessening of tremoring in both hands since discontinuation of Zoloft.  He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:,  Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis.  Parents will call me in two weeks.  I will see him for medication review in four weeks.  Mother signed informed consent.  I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal.  Combination of medication and behavioral intervention is recommended.
Three Views - Ankle  ( Podiatry)
Description:  Pain.  Three views of the right ankle.  Three views of the right ankle are obtained.

EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.
Right Foot Series  ( Podiatry)
Description:  Right foot series after a foot injury.

EXAM: , Right foot series.,REASON FOR EXAM:  ,Injury.,FINDINGS: , Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.
Podiatry - Progress Note  ( Podiatry)
Description:  Plantar fascitis/heel spur syndrome.  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.

SUBJECTIVE:,  Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel.  The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day.  The patient states that he is currently doing no treatment for it.  He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch.  The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:,  Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit.  There is tenderness to palpation to the medial tubercle of the right foot.  The pain is elicited along the medial arch as well.  There are no open areas or signs of infection noted.,ASSESSMENT:,  Plantar fascitis/heel spur syndrome, right foot.,PLAN:,  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.  He was given a low dye strapping and a heel lift was placed in his right shoe.  The patient will be seen back in approximately one month for further evaluation if necessary.  He was told to call if anything should occur before that.  The patient was told to continue with the good work on his diabetic control.
Plantar Fasciitis  ( Podiatry)
Description:  A 44-year-old, 250-pound male presents with extreme pain in his left heel.

S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel.  This is his chief complaint.  He says that he has had this pain for about two weeks.  He works on concrete floors.  He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking.  He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old.  He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face.  He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet.  He has redness of the right toes 2, 3 and 4.  Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1.  Plantar fasciitis.,