smoh/medical-transcriptions huggingface dataset:
GI Consultation - 4  ( Consult - History and Phy.)
Description:  Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.

CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,
Glioma - 2  ( Consult - History and Phy.)
Description:  Headache.  Right frontal lobe glioma.

CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with "bone cancer." AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.
Glioblastoma Multiforme - Consult  ( Consult - History and Phy.)
Description:  Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis. 

REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
Gen Med H&P - 2  ( Consult - History and Phy.)
Description:  Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, 

HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills and sweats.  He denies cough and diarrhea.  He has mild anorexia.,PAST MEDICAL HISTORY:,  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use.  The patient is currently employed.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS:  Blood pressure 96/56, heart rate 120.  No change with orthostatics.  Temperature 101.6 degrees Fahrenheit.  Respirations 30.,HEENT:  Funduscopic examination normal.  He has oral thrush.,LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK:  No goiter, no jugular venous distention.,CHEST:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART:  Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN:  Soft and nontender.,GENITOURINARY:  Normal.,RECTAL:  Unremarkable.,SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8.  Hemoglobin 14, white count 7100, platelet count 515.  Total protein 10, albumin 3.1, AST 131, ALT 31.  Urinalysis shows 1+ protein, trace blood.  Total bilirubin 2.4, direct bilirubin 0.1.  Arterial blood gases:  pH 7.46, pC02 32, p02 46 on room air.  Electrocardiogram shows normal sinus rhythm.  Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1.  Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Thrush.,3.  Elevated unconjugated bilirubins.,4.  Hepatitis.,5.  Elevated globulin fraction.,6.  Renal insufficiency.,7.  Subcutaneous nodules.,8.  Risky sexual behavior in 1982 in Haiti.,PLAN:,1.  Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Begin intravenous Bactrim and erythromycin.,3.  Begin prednisone.,4.  Oxygen.,5.  Nystatin swish and swallow.,6.  Dermatologic biopsy of lesions.,7.  Check HIV and RPR.,8.  Administer Pneumovax, tetanus shot and Heptavax if indicated.
GI Consultation - 1  ( Consult - History and Phy.)
Description:  GI Consultation due to rectal bleeding, positive celiac sprue panel

PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.
GI Consultation - 2  ( Consult - History and Phy.)
Description:  GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.

PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.
Gen Med Consult - 8  ( Consult - History and Phy.)
Description:  Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.

SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.
Gen Med Consult - 45  ( Consult - History and Phy.)
Description:  For evaluation of left-sided chest pain, 5 days post abdominal surgery.

REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08.  The patient underwent laparoscopic appendicectomy by Dr. X.  The patient had postoperative paralytic ileus, which has resolved.  The patient had developed left-sided chest pain yesterday.  In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No recent fever.,ENT:  Unremarkable.,RESPIRATORY:  He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR:  No known heart problems.,GASTROINTESTINAL:  The patient denies nausea or vomiting.  He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY:  ,The patient is a nonsmoker.  He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  An 87-year-old gentleman, not toxic looking.,HEAD AND NECK:  Oral mucosa is moist.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Slightly distended.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ to 3+ pedal swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000.  Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1.  Ruptured appendicitis.  The patient is 6 days post surgery.  He is tolerating oral fluids and moving bowels.,2.  Left-sided chest pain, need to rule out PE by distance of pretty low probability.  The patient, however, has low-oxygen saturation.  We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3.  Fluid retention, manage as per surgeon.,4.  Paralytic ileus, resolving.,5.  Leukocytosis, we will monitor.
Gen Med Consult - 44  ( Consult - History and Phy.)
Description:  An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.

PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.