transcript stringlengths 1.4k 3.82k | structured_note stringlengths 710 2.86k |
|---|---|
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I understand you came in for a routine preventative care visit. What brings you in today?
Patient: Hi doc, I recently noticed some swelling in my left armpit and wanted to get it checked out.
Doctor: I see. Have you ... | S: The patient, who came in for a routine preventative care visit, reported noticing swelling in the left armpit. The patient had a screening mammogram and breast ultrasound, which identified a 5 mm left breast nodule and left axillary adenopathy up to 3.2 cm. The patient underwent a core needle biopsy of the left axil... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, what brings you in today?
Patient: Hi, I've been experiencing impaired vision in both of my eyes for more than a year now.
Doctor: I see. Let's start with an ocular examination to assess your eyes.
(After the examinati... | S: The patient, experiencing impaired vision in both eyes for over a year, reports no known genetic diseases in the family despite parents being first cousins. The patient has a history of developmental retardation and Achilles tendon elongation.
O: Ocular examination reveals vision in the right eye at FC/20 cm and in ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been diagnosed with coronary artery disease and had a stent placement recently. But they found a lung nodule on my chest radiograph at that time.
Doctor: I see. Have you under... | S: The patient, previously diagnosed with coronary artery disease and having undergone stent placement, reports a recent discovery of a lung nodule during a chest radiograph. Subsequent tests including a CT scan and bronchoscopy revealed a 9 mm fatty endobronchial lesion in the bronchus intermedius and a 2 cm extralumi... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 46-year-old woman who has been treated for anaplastic oligoastrocytoma with radiation therapy and is currently taking temozolomide. What brings you in today?
Patient: Hi, Doctor. I've been having a c... | S: The patient, a 46-year-old woman with a history of anaplastic oligoastrocytoma treated with radiation and temozolomide, presents with recent symptoms of cough and palpitations.
O: Vital signs show blood pressure at 115/83 mm Hg, heart rate at 117 beats/min, body temperature at 36.5°C, and SpO2 at 96% on 2 L/min O2 c... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that you are a 40-year-old primiparous woman and you were diagnosed with submucosal fibroids 5 years prior. Can you tell me about the symptoms you experienced at that time?
Patient: Yes, I had atypical geni... | S: The patient is a 40-year-old primiparous woman who initially presented with atypical genital bleeding and hypermenorrhea due to submucosal fibroids, diagnosed 5 years ago. Post-hysteroscopic myomectomy, she developed hypomenorrhea and was later diagnosed with Asherman's syndrome due to intrauterine adhesions and ute... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you were hospitalized in January 2018 for a tumor of the tongue (Fig. a). Can you tell me more about the symptoms you experienced?
Patient: Yeah, I noticed a lump on the left side of my tongue and it was quit... | S: The patient reported a painful lump on the left side of the tongue, which led to the discovery and surgical removal of a tumor. The patient has a history of significant medical conditions including a gastric ulcer, vein thrombosis, and a previous invasive carcinoma of the anal canal treated with radio-chemotherapy. ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, can you tell me what brought you in today?
Patient: Yeah, I came in because I've been having a headache, feeling really tired, and I've got a fever too.
Doctor: I see. When did these symptoms start?
Patient: They sta... | S: The patient reports experiencing headaches, fatigue, fever, nausea, drowsiness, confusion, a stiff neck, and a positive Kernig sign since midnight, June 2014. Symptoms escalated to include signs of meningitis and later, blood sepsis. The patient was initially treated with Amoxicillin, Paracetamol, and Ringer's lacta... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I remember you came to the Oral Surgery and Implantology Department of the University of Barcelona in July 2008. You were completely edentulous and wanted to evaluate your possibilities for oral rehabilitation. How have... | S: The patient, a former heavy smoker and alcohol consumer, has a history of multiple Oral Squamous Cell Carcinomas (OSCC) and is currently undergoing treatment for prostate cancer. He reported a past complication of cervical hematoma post-surgery and mucositis and epithelitis due to radiation therapy. He also mentione... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you were implanted with a dual-chamber implantable cardioverter-defibrillator (ICD) in 2011 for secondary prevention of symptomatic sustained idiopathic VT. Is that correct?
Patient: Yes, that's right.
Doct... | S: The patient, with a history of symptomatic sustained idiopathic ventricular tachycardia (VT), was implanted with a dual-chamber implantable cardioverter-defibrillator (ICD) in 2011 for secondary prevention. Since 2012, the patient has experienced several ICD discharges and VT recurrences despite undergoing three cat... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello! How can I help you today?
Patient: Hi, Doctor. I'm a 45-year-old female, never smoker and without comorbidity. Recently I've been experiencing cough, low grade fever and mild weight loss. There's no haemoptysis though.
... | S: A 45-year-old female, non-smoker with no comorbidities, presents with symptoms of cough, low-grade fever, and mild weight loss. She denies any history of recurrent infections or contact with tuberculosis patients, although she has traveled to Asia and Africa. She was previously diagnosed with pneumonia and treated w... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you were referred to our service 10 years ago after experiencing intermittent disorientation, altered awareness, patchy global amnesia, transient slurred speech, and tremulousness lasting less than 24 hours. ... | S: The patient reports intermittent episodes of left monocular visual blurring and vertical oscillopsia, occurring 1-3 times a month and lasting 20-30 minutes. These episodes are associated with severe left temporal headaches and photophobia, starting within 5 seconds of the visual symptoms. Additionally, the patient e... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you presented to the National Institutes of Health (NIH) Clinical Center in May 2006 for evaluation. What seems to be your chief complaint?
Patient: I am not feeling like myself. I've been experiencing hot fl... | S: The patient, a female with a history of severe depression since age 18, presents with symptoms of hot flashes, night sweats, insomnia, occasional crying episodes, sadness, jitteriness, and a loss of interest in previously enjoyed activities. She reports disturbed sleep and intense hunger during the night. The patien... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you are a 78-year-old Japanese man with a height of 163.3 cm and weight of 61.3 kg. You were admitted to our intensive care unit after undergoing esophagectomy with gastric reconstruction for esophageal cance... | S: The patient is a 78-year-old Japanese man who feels unwell following an esophagectomy with gastric reconstruction for esophageal cancer. He reports new onset fever, increased sputum, hypoxemia, difficulty breathing, and hearing crackling sounds in his chest. His past medical history includes an appendectomy and lumb... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I see that you've been referred for imaging due to a nasal block. Can you tell me more about your symptoms?
Patient: Yes, doctor. I've had a history of recurrent nosebleeds for about 6 to 8 months now. But I haven't ... | S: The patient reports a history of recurrent nosebleeds for approximately 6-8 months. No headaches or other systemic symptoms were noted. The chief complaint was a nasal block.
O: Clinical examination revealed a hard mass protruding through the right nostril. Laboratory tests, including alkaline phosphatase, were with... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you are a 52-year-old African American female who has been referred for evaluation after three years of hydroxychloroquine treatment for rheumatoid arthritis. Can you tell me more about your visual complaints... | S: The patient is a 52-year-old African American female with a history of rheumatoid arthritis treated with hydroxychloroquine for three years. She reports visual complaints that began two years prior to starting the medication, specifically mentioning central vision loss. She denies any nyctalopia or peripheral vision... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, Doctor. I'm gravida 3, para 2, and I came to the emergency department because I've had this hyperpigmented macular and blistering rash on my arms, legs, and trunk for about two wee... | S: The patient, a 32-year-old female, gravida 3, para 2, at 16 weeks gestation, presents with a two-week history of a hyperpigmented macular and blistering rash on her arms, legs, and trunk. She reports the rash as being very pruritic but denies any fever or mucous membrane involvement.
O: Physical examination confirms... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I understand you've been diagnosed with B-ALL and have already experienced a third bone marrow relapse. We're considering enrolling you into our compassionate clinical protocol using TanCAR-T 19/22 cells. Can you tel... | S: The patient, diagnosed with B-ALL in January 2016, presented with a high WBC count (>100 x 10^9/L) and a normal karyotype. After achieving a second complete remission, the patient underwent a haplo-HSCT from their father, followed by complications including hemorrhagic cystitis and stage 1 gastrointestinal acute GVH... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see from your history that you have cerebral palsy, autism, and scoliosis. What brings you to the emergency department today?
Patient: Hi, doctor. I've been experiencing left-sided pleuritic chest pain, shortness of b... | S: The patient, with a history of cerebral palsy, autism, and scoliosis, presents with left-sided pleuritic chest pain, shortness of breath, and fever.
O: Vital signs include sinus tachycardia with a heart rate of 114. Laboratory tests show an elevated white blood cell count at 19,300. Chest radiography reveals left lo... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you had a liver transplant in 1998 due to alcoholic cirrhosis and hepatocellular carcinoma. Can you tell me about any other medical conditions you've had since then?
Patient: Yes, I was diagnosed with diffuse... | S: The patient, a liver transplant recipient from 1998 due to alcoholic cirrhosis and hepatocellular carcinoma, reports a history of diffuse large B-cell lymphoma treated with chemotherapy in 2006, psychiatric illness, and post-traumatic epilepsy. He denies symptoms of encephalopathy. He has experienced intermittent tr... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you have a past medical history of sickle cell trait and you recently presented to a local community hospital with fatigue, arthralgias, and myalgias. Can you tell me more about your symptoms?
Patient: Yes,... | S: Patient, a known carrier of sickle cell trait, presents with a one-week history of fatigue, arthralgias, and myalgias. He reports no recent weight loss, fever, bleeding, bruising, dyspnea, or urinary symptoms. Denies smoking, drug use, and significant travel or risk factors for HIV. Family and medical history are no... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you're a 28-year-old Caucasian male who is single, unemployed, and living alone. You have a positive forensic history and have been diagnosed with Paranoid Schizophrenia. Can you tell me more about your pas... | S: The patient is a 28-year-old Caucasian male with a history of Paranoid Schizophrenia, diagnosed 4 years ago. He reports multiple hospital admissions due to psychosis, totaling five times in the past four years. Despite being stable on Risperdal Consta 37.5 mg fortnightly, Olanzapine 10 mg daily, and Pregabalin 100 m... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, can you tell me about your past medical history? Have you been diagnosed with any chronic conditions?
Patient: Yes, I have chronic obstructive pulmonary disease (COPD).
Doctor: I see. What brings you here today?
Patient... | S: The patient, with a history of chronic obstructive pulmonary disease (COPD), presents with shortness of breath and a productive cough. He reports worsening dyspnea and a productive cough eight weeks post initial admission.
O: Initial CT angiogram revealed spiculated nodules in bilateral lower lobes and right hilar l... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, how can I help you today?
Patient: Hi, my dog has been having some issues with her left eye for about 7 months now. There's been a lot of mucopurulent and hemorrhagic discharge coming from it.
Doctor: I see. Can you ... | S: The patient reports that their dog has been experiencing mucopurulent and hemorrhagic discharge from the left eye for approximately 7 months, which began suddenly after a walk in the park. The patient also notes redness and swelling around the affected eye. No abnormalities are reported in the right eye.
O: Physical... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you've presented at the Rheumatology consultation with complaints of hand and feet arthralgia and oedema evolving for more than 6 weeks. Have you experienced any fever or recent infection?
Patient: No, I haven't h... | S: The patient, with a history of working in endemic areas, presents with complaints of hand and feet arthralgia and oedema persisting for over 6 weeks. The patient denies fever or recent infections and has no history of similar episodes. The patient reports progressive hypostesia/dysestesia of both hands and feet, wit... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I'm Dr. Smith. Can you tell me what brings you here today?
Patient: Hi, Doctor. My 7-year-old son has been having trouble with effort intolerance, but he doesn't have any cyanosis.
Doctor: I see. Let's start with a clin... | S: The patient's mother reports that her 7-year-old son has been experiencing effort intolerance. There are no signs of cyanosis. The chief complaint is primarily related to the child's difficulty in performing activities that require physical exertion.
O: Clinical examination was unremarkable. Doppler echocardiography... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 66-year-old man who presented with a bilateral direct inguinal hernia and benign prostatic hyperplasia. To resolve this problem, we performed a TEP (totally extraperitoneal) procedure using mesh and ... | S: The 66-year-old male patient reports discomfort in the groin area following a TEP procedure for bilateral direct inguinal hernia and a TURP for benign prostatic hyperplasia. He also noted pain and swelling in the right inguinal area postoperatively.
O: The patient underwent TEP and TURP with a total operating time o... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how are you feeling today?
Patient: Not so great, doc. I've got this severe soft tissue infection in my leg.
Doctor: I see. Well, you've been admitted to our emergency hospital for treatment. We'll start you on Ceftriax... | S: The patient reports severe pain and swelling in the leg, diagnosed as a soft tissue infection. No unusual bruising or bleeding noted. The patient is currently on enalapril and simvastatin, with recent additions of Ceftriaxone, clindamycin, and prophylactic enoxaparin.
O: Vital signs are within normal limits. Lab fin... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, Doctor. I've been diagnosed with liver masses and I'm here for a transplantation.
Doctor: I see. Can you tell me more about your symptoms?
Patient: I'm not really sure about the de... | S: The patient reports being diagnosed with liver masses and is present for transplantation consultation. The patient is unsure about specific symptoms but mentions a biopsy confirming the diagnosis.
O: Preoperative imaging reveals an enlarged liver with multifocal disease throughout the hepatic parenchyma, peripheral ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I understand you have been diagnosed with refractory AML and were admitted to our hospital for treatment. We have planned an EMA regimen for you, which includes mitoxantrone, etoposide, and cytarabine. We will need t... | S: The patient, diagnosed with refractory Acute Myeloid Leukemia (AML), expresses concern about the upcoming treatment involving an EMA regimen (mitoxantrone, etoposide, cytarabine). The patient reports feeling okay but is worried about potential treatment side effects.
O: The patient's current hemoglobin level is 9.5 ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I heard you were brought to the emergency department from your nursing home due to respiratory distress and altered mental status. How are you feeling now?
Patient: Yeah, I was having trouble breathing and feeling reall... | S: The patient, a resident of a nursing home, was admitted to the emergency department with respiratory distress and altered mental status. The patient reported difficulty breathing and feeling disoriented. The patient has a significant medical history including an intracranial aneurysm with post-surgical bleeding, isc... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello there, I understand you were referred to our Emergency Department after experiencing a high velocity frontal collision with a car while riding a motorcycle. Can you tell me a bit more about yourself?
Patient: Hi, I'm a 4... | S: 49-year-old Caucasian male, car body repairer, non-smoker, non-drinker, not on any medication, presented to the Emergency Department following a high velocity frontal collision while on a motorcycle. Reports pain in the symphyseal region and left arm. No previous medical history provided.
O: Initial vital signs at s... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've presented with a chief complaint of persistent bright red blood per rectum. Can you tell me more about that?
Patient: Yes, I've been experiencing this bleeding quite recently. It was one large episode ... | S: The patient reports a recent episode of significant bright red blood per rectum with blood clots. The patient has a complex medical history including hypertension, hyperlipidemia, diabetes mellitus type 2, coronary artery disease with three prior myocardial infarctions, recurrent cerebrovascular accidents requiring ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 43-year-old male of Japanese Brazilian descent. What brings you in today?
Patient: Hi, Doctor. I've been experiencing hypesthesia from my right lower lip to the mental region, so I decided to consult... | S: The patient is a 43-year-old male of Japanese Brazilian descent presenting with hypesthesia from the right lower lip to the mental region. He reports moderate physical status and favorable nutritional status, with no other notable factors.
O: The patient's CT scan showed a round radiolucent area in the right mandibu... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I see from your history that you're a 51-year-old female with hypertension and stage 4 human epidermal growth factor receptor 2 (HER-2) positive gastric adenocarcinoma with peritoneal, bone, and lymph nodes metastasi... | S: The patient is a 51-year-old female with a history of hypertension and stage 4 HER-2 positive gastric adenocarcinoma with metastasis to the peritoneum, bones, and lymph nodes. She reports a new onset of a tonic-clonic seizure, which she has never experienced before. She also expresses concern about worsening epigast... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been diagnosed with a sarcoma in 2011 and have had multiple treatments since then.
Doctor: I see, can you tell me about the treatments you've had so far?
Patient: I had my fir... | S: The patient, previously diagnosed with sarcoma in 2011, reports multiple treatments including surgical interventions, chemotherapy, and radiotherapy. The patient experienced local and distant disease progression, with the most recent treatments being high-dose chemotherapy and microwave ablation for pulmonary metast... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you're here today because your 12-month-old son has been referred to us due to an unsymmetrical bilateral cleft lip and palate, causing a protruding premaxilla. Is that correct?
Patient: Yes, that's right.
... | S: The patient's mother reports that her 12-month-old son was referred for treatment of an unsymmetrical bilateral cleft lip and palate with a protruding premaxilla.
O: Surgical intervention involved the removal of approximately 3 mm of bone from the vomer, located posterior to the vomeroperpendicular suture (VPS), to ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're here for a follow-up appointment regarding chronic back pain control. How have you been managing your pain with methadone?
Patient: It's been helping a bit, but I've been struggling with some other iss... | S: The patient reports chronic back pain, managed partially with methadone, and worsening dyspnea requiring increased oxygen supplementation. The patient has a history of morbid obesity, obstructive sleep apnea, acute lymphocytic leukemia with bone marrow transplant and graft-versus-host disease, leading to severe rest... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've been referred by your general practitioner to our Department of Oral and Maxillofacial Surgery. You have presented with a 4-week history of suspicious upper lip swelling, is that correct?
Patient: Yes,... | S: The patient, referred by a general practitioner to the Department of Oral and Maxillofacial Surgery, reports a 4-week history of sudden, painful swelling of the upper lip. The patient denies any specific trauma but admits to self-injecting a dermal filler purchased online into the upper lip, which coincides with the... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've brought your two-year-old boy to the emergency department with respiratory distress but no fever. Can you tell me a little more about his medical history?
Parent: Sure, doctor. He doesn't have a pathol... | S: The patient, a two-year-old boy, presented to the emergency department with respiratory distress but no fever. The parent reported that the child had a month-long history of repeated attacks of cough and wheezing, worsening despite treatment with antibiotics and steroids for suspected asthma. There was no history of... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, doctor. I was diagnosed with IPF about 5 years ago, and I've been undergoing oral nintedanib therapy with LTOT. Recently, I've been experiencing respiratory distress and worsening ... | S: The patient, diagnosed with idiopathic pulmonary fibrosis (IPF) 5 years ago, reports recent respiratory distress and worsening cough. He has been on oral nintedanib therapy and long-term oxygen therapy (LTOT). He also mentioned a chronic cough associated with IPF, which has deteriorated continuously starting about 3... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you are a 23-year-old African American man with a history of bipolar disorder. Could you please tell me your current symptoms?
Patient: Yeah, I've been feeling really out of it mentally, and I've been throw... | S: The patient is a 23-year-old African American male with a history of bipolar disorder, currently experiencing mental disorientation and frequent vomiting. He reports a history of adverse reactions to various medications, including diarrhea with lithium, leading to a trial of Valproic Acid (VA) which was initiated fo... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've presented to the Emergency Department of Chitwan Medical College with a history of weakness in both lower limbs for two days, preceded by muscle cramps of three days' duration. Can you tell me more abo... | S: The patient, a 34-year-old male, presented with a chief complaint of progressive weakness in both lower limbs over two days, which then affected the upper limbs. The onset was insidious, and the weakness was preceded by muscle cramps lasting three days. The patient denied any altered sensorium, seizure, or bladder o... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I am here to report the case of a 47-year-old male patient from Mali, West Africa. Can you please tell me more about the symptoms you experienced?
Patient: Yeah, for the past three weeks, I've been having intermittent f... | S: A 47-year-old male from Mali presents with a three-week history of intermittent fever, chills, increased fatigue, decreased appetite, diffuse back and abdominal pain, and significant weight loss of 35 pounds over three months. He reports a history of malaria treated six months ago and recent travel in Africa.
O: On ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you have been referred to our hospital for massive hemoptysis. Can you tell me more about your symptoms?
Patient: Yes, doctor. I've been coughing up a lot of blood recently.
Doctor: I understand. Your medical hist... | S: The patient reports massive hemoptysis as the chief complaint. He has a history of chronic heart failure, moderate mitral regurgitation, atrial fibrillation, and chronic kidney disease. He is currently on apixaban and pilsicainide for atrial fibrillation management.
O: Upon admission, the patient was severely hypoxi... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that you are a 19-year-old man who has recently been experiencing polydipsia, polyuria, and muscle weakness for more than a month. Is that correct?
Patient: Yes, that's right. I've also developed vomiting a... | S: The patient is a 19-year-old male presenting with symptoms of polydipsia, polyuria, muscle weakness, vomiting, and transient paralysis. He reports these symptoms have persisted for over a month. He has no personal or family history of neuromuscular, thyroid, or autoimmune diseases. He was previously hospitalized wit... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, Doctor. I've been experiencing some severe headaches and dizziness recently.
Doctor: I see. Let me review your medical history. It seems you underwent direct bypass surgery for an ... | S: Patient reports severe headaches and dizziness. History of direct bypass surgery for intraventricular hemorrhage at age 50. Concerns about recurrent bleeding 17 months post-surgery.
O: Follow-up digital subtraction angiography (DSA) indicates partial supply (about 2/3) of the middle cerebral artery (MCA) territory, ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you've presented to the emergency room with a severe, excruciating headache. Can you tell me more about your symptoms?
Patient: Yeah, I've had this headache for about an hour now, and it started after I used meth.... | S: The patient, a known methamphetamine user, presents with a severe headache, nausea, vomiting, neck pain and stiffness, and photophobia. The headache began about an hour after meth use. The patient has a history of meth use via oral, snorting, and intravenous routes. This is a recurrent presentation similar to an epi... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you're 16 weeks into your pregnancy. How can I help you today?
Patient: Hi, Doctor. For the past two months, I've been having terrible nausea, non-bloody emesis, and poor oral intake.
Doctor: I'm sorry to hear tha... | S: The patient, a 16-week pregnant female, reports persistent nausea, non-bloody vomiting, and poor oral intake for the past two months. She experienced a syncopal episode with mild abdominal pain and was diagnosed with leukocytosis, hyponatremia, hypokalemia, elevated liver enzymes, and ketonuria at another hospital. ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, Doctor. I've been having progressive shortness of breath and leg swelling recently.
Doctor: I'm sorry to hear that. Can you tell me about your past medical history?
Patient: Sure. ... | S: The patient, a male with a history of HIV disease and metastatic transitional cell cancer of the renal pelvis, presented with progressive shortness of breath and leg swelling. He reported undergoing a left nephrectomy and having metastatic involvement in spinal bones, mediastinal lymph nodes, and lungs. He was treat... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi, I understand you have a history of NF1 and you've presented to the emergency department with palpitations, flushing, pounding headache, numbness, tingling in both arms, and shortness of breath for the past two hours. Is th... | S: The patient, with a history of Neurofibromatosis type 1 (NF1) and Takotsubo Syndrome (TS), reports experiencing palpitations, flushing, pounding headache, numbness, tingling in both arms, and shortness of breath for the past two hours. These symptoms have recurred every two to three months over the past two years. T... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how are you feeling today?
Patient: Hi, I'm feeling better than before, but still struggling with some issues.
Doctor: I see. I understand you have Type 1 Diabetes and have been dealing with gastroparesis and End-Stage ... | S: The patient, with a history of Type 1 Diabetes, gastroparesis, and End-Stage Renal Disease (ESRD) requiring peritoneal dialysis, reports feeling better post-Simultaneous Kidney-Pancreas (SKP) transplant. The patient notes significant improvement in blood sugar levels.
O: Pre-transplant HgbA1c was 7.2%, which decreas... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you've been experiencing a dry cough for about 3 months, and lately, you've noticed some bloody sputum. Is that correct?
Patient: Yes, that's right.
Doctor: I have reviewed your test results, and it seems t... | S: The patient reports a persistent dry cough for approximately 3 months and recent episodes of bloody sputum. The patient expressed concern upon learning of the diagnosis.
O: The patient's diagnostic tests, including an acid-fast bacterium smear and PCR for M. tuberculosis, returned positive results, confirming tuberc... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've brought your 13-month-old daughter in today. She was presented to the emergency department for urinary retention, is that correct?
Adoptive Parent: Yes, that's correct.
Doctor: I understand that she wa... | S: The patient, a 13-month-old female, presented with urinary retention and has a history of being born preterm at 35 weeks in Mexico with an unknown postnatal course. She has been diagnosed with mild gross motor developmental delay and currently exhibits fussiness, decreased ability to bear weight on lower extremities... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Good morning, how can I help you today?
Patient: Hi, doctor. I have been experiencing increasing pain in my right knee recently.
Doctor: I see. Can you please tell me about your past medical history?
Patient: Sure. I have type... | S: Patient reports increasing pain in the right knee. History includes type 2 diabetes mellitus treated with insulin, BMI of 35.5 kg/m2, arterial hypertension, restless leg syndrome, and previous right knee surgeries including total knee arthroplasty and revision for instability. No complications from past surgeries we... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you've been referred to our institution for secondary infertility. Can you tell me a bit about your situation?
Patient: Yes, I had a caesarean section 8 years ago and I've been trying to get pregnant for the last ... | S: The patient, a female with a history of cesarean section 8 years ago, reports secondary infertility for the past 3 years. She mentions regular menstrual cycles with slight dysmenorrhea. Menarche occurred at 14 years of age.
O: Physical examination of the external genitalia and vagina showed normal findings. Notably,... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, how can I help you today? What brings you to the emergency department?
Patient: Hi, Doctor. I've been feeling really weak and tired. I've been experiencing nausea, vomiting, and I can't tolerate food. My vision is al... | S: The patient, a known case of Systemic Lupus Erythematosus (SLE) with a history of idiopathic pancreatitis, presented with complaints of weakness, tiredness, nausea, vomiting, inability to tolerate food, blurry vision, and abdominal pain. The patient reported no history of diabetes or autoimmune diseases other than S... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 53-year-old female with a past medical history of aortic regurgitation and hypertension. You're here for a routine cardiology follow-up, right?
Patient: Yes, that's correct.
Doctor: Have you experien... | S: The patient is a 53-year-old female with a history of aortic regurgitation and hypertension, presenting for a routine cardiology follow-up. She reports no recent symptoms of chest pain, shortness of breath, orthopnea, dyspnea, or leg swelling.
O: Physical examination revealed normal vital signs and a diastolic murmu... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you've come to the emergency department due to dyspnea and a history of lower extremity edema. Can you tell me more about your symptoms?
Patient: Yes, for the past 6 months, I've had swelling in my legs, and it's ... | S: The patient presented with a 6-month history of lower extremity edema and dyspnea, and a 3-month history of intermittent abnormal vaginal bleeding. The patient reported symptomatic improvement following pericardiocentesis.
O: Initial evaluation showed hypoxemia with an oxygen saturation of 80% on room air, tachycard... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how are you today?
Patient: Not so good, doc. I had a road traffic accident yesterday and ended up in the emergency department.
Doctor: I'm sorry to hear that. Let me take a look at your history and the results of your ... | S: The patient reports being involved in a road traffic accident, resulting in a visit to the emergency department. He complains of symptoms consistent with significant head trauma, including right otorrhea and ecchymosis of both eyes. He has a history of old orthopedic instrumentation from a previous surgery 30 years ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, can you tell me about your past medical history?
Patient: Sure, I've had recurrent sinusitis and otitis media since I was young. I had a bilateral tympanostomy tube placement and tonsillectomy at age 4, and I've been ge... | S: The patient, a young individual with a history of recurrent sinusitis, otitis media, bilateral tympanostomy tube placement, tonsillectomy, and ongoing allergen immunotherapy for environmental allergies, presents with a chief complaint of irritation, redness, and a sensation of a mobile, swimming foreign body in the ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I'm here for a follow-up. I was diagnosed with POAG ten years ago and have been suffering from eye discomfort in my right eye.
Doctor: I see. You've been under treatment with hypot... | S: The patient, diagnosed with Primary Open-Angle Glaucoma (POAG) ten years ago, reports persistent eye discomfort in the right eye, characterized by burning, itchiness, and a sensation of sand, despite treatment with various tear substitutes. The discomfort has been particularly severe over the past six months. The pa... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been having chronic headaches for years, and they've been getting worse lately.
Doctor: I'm sorry to hear that. Can you tell me more about your symptoms and when they started?... | S: The patient reports chronic headaches that began approximately twelve years ago, initially mild but have progressively worsened to severe headaches accompanied by vertigo, nausea, vomiting, unsteadiness of gait, and right-sided body numbness. These episodes last 2-3 days. The patient has a history of neurological de... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I understand you've been experiencing some unexplained weight loss and abdominal pain recently. Can you tell me more about your symptoms?
Patient: Yeah, I've lost over 10 kg in the past 6 months, and I've been having... | S: Patient reports a significant unexplained weight loss of over 10 kg in the past 6 months and nonspecific abdominal pain. No changes in bowel habits or appetite were noted.
O: Vital signs are within normal limits; however, patient appears pale. Physical examination revealed a palpable fist-sized mass in the left uppe... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, what brings you to the emergency department today?
Mother: Hi, my son had an episode of hemoptysis just before we arrived here. He's been coughing up blood.
Doctor: I see. Has he been experiencing any other symptoms rec... | S: The patient, a young child, presented with hemoptysis, cold-like symptoms, vomiting, diarrhea, and a recent fever peaking at 101º F. The mother reports the child attends daycare where there is a current outbreak of RSV. The child has a history of multiple bronchitis infections and is adopted with an unknown family m... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello MF, I understand you were referred to our tertiary centre after having two endoscopic endonasal sinus operations in the past 18 months. How have you been feeling since those procedures?
Patient: Well, I still have this c... | S: The patient, MF, reports persistent symptoms of chronic rhinosinusitis and a bothersome left frontal mucocoele despite two previous endoscopic endonasal sinus surgeries within the last 18 months. MF also mentions ongoing significant ptosis post-ophthalmological intervention and recurrent left-sided headaches associa... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been having migraines lately, and I'm not sure what's causing them.
Doctor: I see. Have you had any recent accidents or injuries?
Patient: Yeah, I was in a road traffic accide... | S: The patient reports experiencing migraines, which began following a road traffic accident resulting in a craniocerebral injury and a tracheostomy. The patient has a history of rheumatoid arthritis for 3 years, managed with methotrexate (2.5 mg three times per day) and topiramate (200 mg twice a day) for migraines.
O... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello. You mentioned that you recently presented to our hospital with dyspnea. Can you tell me if you have experienced any other symptoms recently?
Patient: Yes, I developed general fatigue about 5 years ago and numbness on th... | S: The patient reports a history of general fatigue for 5 years, numbness on the right side of the body for 3 years, and dyspnea on exertion for 1 year. The patient has experienced a weight loss from 46 to 41 kg over the past 5 years. Previously diagnosed with ossification of the posterior longitudinal ligament (OPLL) ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you have a family history of colon cancer, with your paternal grandfather and uncle being affected. What brought you to the emergency department today?
Patient: Hi, Doctor. I've been experiencing generalize... | S: The patient, with a family history of colon cancer, presents with generalized abdominal pain, nausea, unintentional weight loss of four pounds, and shortness of breath for approximately one week.
O: Vital signs were not specified. Blood work revealed elevated liver enzymes and bilirubin levels. Fecal occult blood te... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I'm a 29-year-old, non-lactating, and non-gravid woman, and I've come here with a complaint of a lump in my right breast. I also have a low-grade fever and some unilateral pain in ... | S: The patient is a 29-year-old, non-lactating, non-gravid woman presenting with a chief complaint of a lump in her right breast, accompanied by low-grade fever and unilateral pain in the breast tissue.
O: Physical examination revealed a 1 cm erythematous, tender mass in the right breast, with no nipple discharge, axil... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you were admitted to the emergency department in December 2017 with a sudden-onset tonic-clonic seizure and status epilepticus. Can you tell me more about that?
Patient: Yes, it was really frightening. I sudd... | S: The patient reported a sudden-onset tonic-clonic seizure in December 2017, which was described as frightening and uncontrollable. The patient has a history of left maxillary sinus diffuse large B-cell lymphoma (DLBL) diagnosed in July 2009, presenting initially with left facial swelling, erythema, and pressure sensa... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're an 81-year-old female who presented to our tertiary referral centre with non-specific epigastric pain of increasing severity and frequency. Your comorbidities are limited to hypertension. Can you tell ... | S: 81-year-old female presents with non-specific, worsening, and frequent epigastric pain. She has a history of hypertension. No other significant medical history reported.
O: CT angiography revealed a 67-mm infrarenal abdominal aortic aneurysm (AAA) extending to the aortic bifurcation without intraluminal thrombus. Th... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you've been referred to our department for treatment of a right kidney tumor and IVC thrombus. Can you tell me more about your symptoms?
Patient: Sure, I've been experiencing some discomfort and pain in the... | S: The patient, referred for treatment of a right kidney tumor and IVC thrombus, reports discomfort and pain on the right side of the abdomen. The patient has undergone a right nephrectomy to address these issues.
O: CTAG results classified the kidney tumor as level II. Pre-operative lab results showed Hb 83 g/L, CRP 5... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I have a report here regarding your medical history. You were diagnosed with clear cell renal cell carcinoma (ccRCC) of the right kidney and underwent a radical nephrectomy, correct?
Patient: Yes, that's right. I had th... | S: The patient, a long-term survivor of clear cell renal cell carcinoma (ccRCC), initially presented with a right kidney tumor treated with radical nephrectomy 16 years ago. Six years post-nephrectomy, the patient developed a multi-focal lesion in the head of the pancreas, initially thought to be a solitary lesion, tre... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, sir. I see that you presented to our outpatient clinic in August 2011 with left vision deterioration. Can you tell me more about your vision problem?
Patient: Yes, my left eye's vision has been getting worse over time.
... | S: The patient, a male, reported progressive deterioration of vision in his left eye. He has been under treatment for polypoidal choroidal vasculopathy (PCV) since his diagnosis in August 2011. He expressed concerns about the effectiveness of the ongoing treatment.
O: The patient's best corrected visual acuity (BCVA) w... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello Mr. G, I see here that you're a 39-year-old Asian British man, married and currently unemployed, living with your family. You have a long forensic history. Can you tell me about your experience with Bipolar Disorder?
Pat... | S: Mr. G, a 39-year-old Asian British male, reports a history of Bipolar Disorder diagnosed at age 28, with multiple hospital admissions and difficulties adhering to treatment and engaging with community teams. He has a history of poly-substance misuse including alcohol, cocaine, MDMA, cannabis, and "legal highs." He d... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I'm here to discuss your daughter's medical history and recent genetic testing. She was born via Caesarean section at 32 weeks gestational age to you, a 31-year-old gravida 4 para 3 mother. Was the pregnancy course unco... | S: The patient, a 10-month-old female born prematurely at 32 weeks via Caesarean section, presented for a medical genetics consultation. The mother reports a smooth pregnancy with no prenatal genetic testing indicated. Post-delivery, the patient experienced intraventricular hemorrhage and stayed in the NICU for 2 month... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 51-year-old male patient with a history of asthma managed with β2 adrenergic receptor agonists like salbutamol. What brings you to the asthma clinic at the University hospital of Verona today?
Patien... | S: The patient is a 51-year-old male with a history of asthma, currently managed with β2 adrenergic receptor agonists such as salbutamol. He reports experiencing increased wheezing, coughing, whistling sounds during breathing, and worsening dyspnea over the last 24 hours.
O: Physical examination revealed wheezing durin... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I have your test results from your fundus examination and optical coherence tomography (OCT) back in November 2012. It seems that you were diagnosed with wet AMD in your left eye due to the onset of metamorphopsia. At t... | S: The patient reports a history of wet age-related macular degeneration (AMD) in the left eye, initially diagnosed in November 2012, with symptoms of metamorphopsia. The patient has a 20-year history of well-controlled hypertension treated with an angiotensin-converting enzyme inhibitor and a thiazide diuretic. The pa... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi, I see from your medical history that you had a splenectomy due to a splenic artery rupture. What brings you here today?
Patient: Hi, doc. I have been experiencing diffuse abdominal pain for the past day. It's been accompan... | S: The patient, with a history of splenectomy due to splenic artery rupture, presents with diffuse abdominal pain for the past day, accompanied by nausea and two episodes of non-bilious, non-bloody vomiting. The patient denies any relation of the pain to food intake or recent antibiotic use and reports no fever, chills... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you were diagnosed with metastatic melanoma (cTx, pN1b, M1) in February 2019. Can you tell me what symptoms led you to seek medical attention?
Patient: Hi, doctor. I first presented with left inguinal swellin... | S: The patient, diagnosed with metastatic melanoma (cTx, pN1b, M1) in February 2019, initially presented with left inguinal swelling lasting four months. Symptoms leading to the diagnosis included generalized weakness, extreme fatigue, lethargy, myalgia, poor appetite, weight loss, and mood changes over a period of 6-8... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I'm Dr. Smith. Can you please tell me about your medical history and any symptoms you've experienced?
Patient: Yeah, so since I was 11, I've had polyuria and polydipsia. I guess I kind of neglected it, though.
Doctor... | S: The patient, aged 20 years, reports long-standing symptoms of polyuria and polydipsia since age 11, and more recently, polyphagia and significant weight gain from 60 to 90 kg. The patient has a history of medical evaluations at ages 14 and 17, which ruled out diabetes mellitus due to absence of hyperglycemia. No oth... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you have a history of myelodysplastic syndrome that progressed to acute myeloid leukemia. You underwent an allogeneic hematopoietic stem cell transplant in 2013 and had numerous complications, including graft... | S: The patient, with a history of myelodysplastic syndrome progressed to acute myeloid leukemia, reports severe fatigue, aching abdominal pain localized to the upper abdomen radiating into the back, headache, nausea, and diaphoresis. No fevers were reported. The patient underwent two allogeneic hematopoietic stem cell ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've presented to the Department of Gynecology for a physical examination. Have you experienced any unusual symptoms lately?
Patient: No, I haven't noticed any symptoms or issues.
Doctor: Alright. We've con... | S: The patient, a female with a history of a borderline ovarian tumor treated with laparoscopic ovarian cystectomy eight years ago, presented to the Department of Gynecology for a routine physical examination. She reported no symptoms or issues prior to the examination.
O: Recent imaging studies, including ultrasonogra... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I understand that you recently underwent surgery for concomitant exotropia under local anesthesia. How have you been feeling since the surgery?
Patient: Yeah, I've been doing okay, I guess.
Doctor: Two weeks after yo... | S: The patient reports feeling "okay" following surgery for concomitant exotropia performed under local anesthesia. The patient noticed and was uncomfortable with a conjunctival cyst and congestion on the left temporal side, which developed two weeks post-surgery. The patient initially adhered to the prescribed treatme... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see from your history that you're an 82-year-old Japanese man with a 10-year history of rheumatoid arthritis (RA). You've presented today with a fever and malaise. Can you tell me more about how you're feeling?
Patien... | S: 82-year-old Japanese male with a 10-year history of rheumatoid arthritis (RA), currently on MTX 12 mg/week, prednisolone 2.5 mg/day, and bucillamine 100 mg/day, presents with fever and malaise. He reports feeling weak and tired, exacerbated by the fever. He has a history of benign prostatic hyperplasia and gout, and... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, you must be the patient. I've read that you're a 56-year-old married, retired Caucasian male with a 6-year history of Parkinson's Disease (PD). Is that correct?
Patient: Yes, that's right. I used to work in a scientific... | S: 56-year-old retired Caucasian male with a history of Parkinson's Disease (PD) for 6 years reports worsening left-handed tremor and bradykinesia despite treatment with carbidopa-levodopa and Deep Brain Stimulation (DBS) in the left VIM for right-handed tremor. He also reports behavioral changes including apathy, poor... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I have been suffering from ankylosing spondylitis for the past 10 years and recently, I've been feeling really fatigued.
Doctor: I see. Have you experienced any fever, nausea, vomi... | S: The patient, who has been suffering from ankylosing spondylitis for 10 years, reports recent significant fatigue. He denies experiencing fever, nausea, vomiting, diarrhea, confusion, or headaches. He has been on certolizumab pegol for the past 6 months, initially dosed at 400 mg followed by 200 mg every 2 weeks. He ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, sir. I understand you have a history of HBV-related cirrhosis. Can you tell me more about your symptoms?
Patient: Yeah, I've been feeling tired and having some abdominal pain lately.
Doctor: I see. You were referred to ... | S: The patient, with a history of HBV-related cirrhosis, reported feeling tired and experiencing abdominal pain. He was diagnosed with liver cancer in May 2011 but had not received any treatment for it prior to the current consultation.
O: The patient's alpha-fetoprotein serum level was elevated at 123.5 ng/mL (normal ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how are you feeling today?
Patient: Not so great, I've been having worsening shortness of breath, right upper quadrant pain, nausea, emesis, and a fever for about a week now.
Doctor: I see. You mentioned you're a 60-yea... | S: The patient, a 60-year-old morbidly obese white female, reports worsening shortness of breath, right upper quadrant pain, nausea, emesis, and fever for about a week. She has a history of severe cholecystitis managed with a percutaneous cholecystostomy drain last year.
O: Physical examination revealed a large, fluctu... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I have been experiencing a chronic mild headache for quite some time now.
Doctor: I see. Have you had any tests done for this?
Patient: Yes, I went to another hospital's neurosurgi... | S: The patient reports chronic mild headaches and has been diagnosed with a small mass lesion in the sella turcica. The patient has elevated serum GH (6.83 ng/ml) and IGF-1 (517 ng/ml) levels. There are no neurological deficits, hypertension, diabetes, or family history of cancer or endocrinological diseases. The patie... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, Doctor. I've been suffering from vertigo for about a year now.
Doctor: I'm sorry to hear that. Can you tell me when these vertigo spells usually happen?
Patient: They mostly happen... | S: The patient reports experiencing vertigo for approximately one year, primarily triggered during coitus at orgasm and also during swimming and intense exercise. The vertigo episodes are brief, lasting about 5 minutes, and are accompanied by nausea, vomiting, urge to defecate, and hyperacusis. The patient denies exper... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that you've been experiencing some issues with your vision. Can you tell me what you've noticed?
Patient: Yes, back in October 2013, I saw a blind spot in the central vision of my left eye.
Doctor: I see. W... | S: The patient reported a blind spot in the central vision of the left eye since October 2013. The patient noted a slight improvement in vision following initial treatment but stated that the vision is still not perfect.
O: Initial diagnosis was a small macular hole (MH) with an adhesion expanse of 218 μm. Best-correct... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been having issues with my vision. I'm experiencing vertical diplopia and my eyelids are drooping.
Doctor: I see. Has this been happening consistently or does it worsen with s... | S: Patient reports experiencing vertical diplopia and ptosis, worsening when looking left and down. Symptoms began three days after receiving the second dose of the HPV nine-valent vaccine. Additional symptoms include difficulty speaking and swallowing. No prior history of similar symptoms was mentioned.
O: Physical ex... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I developed some pain in my right lower jaw back in February 2014.
Doctor: I see. Do you have any history of calcium or other metabolic bone disorders, like Paget's disease? Are yo... | S: The patient, who has no history of calcium or metabolic bone disorders and no chronic medication use, reported experiencing pain in the right lower jaw since February 2014. The patient denies any radiation exposure. Previously diagnosed with a giant cell lesion in the right posterior mandible, the patient is current... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been dealing with jaundice for about a month now. I'm also experiencing generalized pruritus, epigastric pain, anorexia, and weight loss.
Doctor: I see. Let's start with a cli... | S: The patient reports experiencing jaundice for about a month, accompanied by generalized pruritus, epigastric pain, anorexia, and weight loss.
O: Clinical examination revealed the patient to be thin built and icteric with a palpable gall bladder. Liver function tests indicated obstructive jaundice with total bilirubi... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that your 4-month-old son was referred to our center following a routine examination. Can you tell me more about the findings during that examination?
Mother: Yes, the doctor said they found bilateral retin... | S: The mother reports that her 4-month-old son was diagnosed with bilateral retinal folds and heavy exudation in the right eye, suspected to be Familial Exudative Vitreoretinopathy (FEVR). She is currently pregnant and concerned about the genetic transmission of FEVR to her unborn child. The family history includes a c... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, you must be the 12-year-old boy who presented to our outpatient clinic here at Tabarak Allah Rural Hospital in Gedaref State. How can I help you today?
Patient: Hi, doctor. I've been having complaints of fever, chills, ... | S: A 12-year-old boy from Barbar El Fugara village, an endemic area for visceral leishmaniasis in Sudan, presents with a one-week history of fever, chills, headache, dry cough, and vomiting. He reports loss of appetite over the last two days and denies any past history of visceral leishmaniasis.
O: Physical examination... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I see that you have a past medical history of hypertension, obesity, and gastroesophageal reflux disease. What brings you in today?
Patient: Hi, doctor. I've been having abdominal pain in the right upper quadrant for... | S: Patient reports a history of hypertension, obesity, and gastroesophageal reflux disease. He presents with an eight-day history of right upper quadrant abdominal pain, nausea, vomiting, fevers, and diarrhea.
O: Vital signs on admission include blood pressure 130/90 mmHg, heart rate 133 bpm, respiratory rate 18 breath... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I'm Dr. Smith, and I'll be taking care of you today. I just received your medical report. Can you tell me about your medical history?
Patient: Yeah, I'm 70 years old, and I have a history of dyslipidaemia. I also have a... | S: The patient is a 70-year-old male with a history of dyslipidemia and smoking. He reports having suffered an ST elevation myocardial infarction (STEMI), followed by thrombolysis due to the unavailability of immediate percutaneous coronary intervention (PCI). Post-thrombolysis, he developed advanced atrioventricular b... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you have a history of cutaneous melanoma. Can you tell me what brings you here today?
Patient: Hi, yes. I was recently admitted to the Thoracic Surgery Unit of Policlinico Umberto I because of the appearance of so... | S: The patient, with a history of cutaneous melanoma, presented due to pulmonary nodules identified in a follow-up exam, which included both PET and CT scans. The patient was asymptomatic, afebrile, and in good condition during the physical examination. The patient reported a recent wedge resection in the right lower l... |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.