smoh/medical-transcriptions huggingface dataset:
Consult - Smoking Cessation   ( Consult - History and Phy.)
Description:  The patient needs refills on her Xanax

CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.
Consult - Screening Colonoscopy  ( Consult - History and Phy.)
Description:  Patient comes for discussion of a screening colonoscopy. 

HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.
Consult - Hydronephrosis  ( Consult - History and Phy.)
Description:  Marked right hydronephrosis without hydruria. 

CHIEF COMPLAINT:,  Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma.  She is scheduled to undergo mastectomy in two weeks.  In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation.  Again, she is scheduled for mastectomy in two weeks.  She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney.  There was no dilation of the right ureter noted.  Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:,  Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:,  None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  She is retired.  Does not smoke or drink.,REVIEW OF SYSTEMS:,  I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:,  Please see the physical exam sheet I completed.  Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria.  She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005.  I will try to obtain the report to see if the right kidney was evaluated at that time.  She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney.  She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed.  She will call us back to schedule the x-rays.  She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer.  There is also a question of a stone present in the kidney.  She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.
Consult - Laparoscopic Cholecystectomy   ( Consult - History and Phy.)
Description:  Patient with mid-epigastric abdominal pain.  Sonogram revealed gallstones.

PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed.  She is married.  She is in sales.  She does not smoke.  She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec.  She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:,  Negative for heart, lungs, GI, GU, cardiac, or neurologic.  Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile.  Vital Signs are stable.  HEENT:  EOMI.  PERRLA.  Neck is soft and supple.  Lungs clear to auscultation.  She is mildly tender in the abdomen in the right upper quadrant.  No rebound.  Abdomen is otherwise soft.  Positive bowel sounds.  Extremities are nonedematous.  Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications.  She understands and we will proceed with the surgery in the near future.,
Consult - Hypertension  ( Consult - History and Phy.)
Description:  Patient with a past medical history of hypertension for 15 years.

HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.
Consult - Coronary Artery Disease  ( Consult - History and Phy.)
Description:  Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG:
Consult - Back & Leg Pain  ( Consult - History and Phy.)
Description:  The patient has been suffering from intractable back and leg pain.

Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,
Consult - Breast Cancer  ( Consult - History and Phy.)
Description:  Patient presents with complaint of lump in the upper outer quadrant of the right breast

CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:,  Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.
Consult - Cerebral Peduncle Infarction  ( Consult - History and Phy.)
Description:  Patient with a history of right upper pons and right cerebral peduncle infarction.

FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.
Consult - Atrial Fibrillation - 1  ( Consult - History and Phy.)
Description:  Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.

REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION: