Clinical NER Dataset
Collection
Publically available clinical NER datasets • 4 items • Updated • 1
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Sample Type / Medical Specialty: General Medicine
Sample Name: Disseminated Intravascular Coagulation
Description: Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.
(Medical Transcription Sample Report)
DIAGNOSES:
1. Disseminated intravascular coagulation.
2. Streptococcal pneumonia with sepsis.
CHIEF COMPLAINT: Unobtainable as the patient is intubated for respiratory failure.
CURRENT HISTORY OF PRESENT ILLNESS: This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.
PAST MEDICAL HISTORY: Otherwise nondescript as is the past surgical history.
SOCIAL HISTORY: There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.
FAMILY HISTORY: Otherwise noncontributory.
REVIEW OF SYSTEMS: Not otherwise pertinent.
PHYSICAL EXAMINATION:
GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated.
VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.
HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place.
NECK: No jugular venous pressure distention.
CHEST: Coarse breath sounds bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line.
EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.
LABORATORY STUDIES: The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.
IMPRESSION/PLAN: At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.
Keywords:
general medicine, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated,
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... | train/104_20210112211707 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary - 2
Description: The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions.
(Medical Transcription Sample Report)
The patient is a 69-year-old female, who was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions from her initial evaluation on 12/01/08 to her last session on 01/09/09.
The patient made some progress during therapy. She accomplished two and a half out of her five short-term therapy goals. We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits. The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently. The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect. She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently. Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect. The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9. Her last session occurred on 01/09/09. She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.
Keywords:
discharge summary, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speech,
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Death Summary - 1
Description: Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.
(Medical Transcription Sample Report)
The patient pronounced expired at 01:40 hours.
DISCHARGE DIAGNOSES:
1. Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.
2. Respiratory failure secondary to above.
3. Likely postobstructive pneumonia.
4. Gastrointestinal bleed.
5. Thrombocytopenia.
6. Acute renal failure.
7. Hyponatremia.
8. Hypercalcemia, likely secondary to paraneoplastic syndrome from the non-small cell lung CA, possible metastases to the bones.
9. Leukemoid reaction, likely secondary to malignancy.
10. Elevated liver function tests.
HOSPITAL COURSE: This is a 53-year-old African American male patient of Dr. X who was admitted through the emergency room. He has been having some right hip pain and cough. The patient had a CT scan of the chest, which revealed a left pleural effusion, extensive mediastinal mass, left hilar adenopathy, causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein, and the multiple nodules on the right side of his chest. These were all consistent with metastatic disease. He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion. The patient had severe shortness of breath, chest pain, a left-sided chest tube was inserted, and pleural effusion was positive for malignant cells. The history of right hip pain could be secondary to metastatic disease. The patient underwent bronchoscopy, which is positive for non-small cell lung CA. The patient was seen by various consultants. The patient underwent respiratory failure, requiring intubation, mechanical ventilatory support. He was extubated, but had to be re-intubated because of respiratory failure. Had a long discussion with the patient's wife and other family members. The patient was seen by Dr. Y. The patient was not in a condition to undergo any kind of chemotherapy, being on the ventilator. The patient progressively got deteriorated. The patient's family requested for DNR, withdrawal of the life support. The patient was extubated, and he was pronounced expired on 08/21/08 at 01:40 hours.
I appreciate all consultants' input.
Keywords:
discharge summary, dnr, pronounced expired, extubated, death summary, lung carcinoma, pleural effusion,
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Post Thyroidectomy - Discharge Summary
Description: Symptomatic thyroid goiter. Total thyroidectomy.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS: Symptomatic thyroid goiter.
DISCHARGE DIAGNOSIS: Symptomatic thyroid goiter.
PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: Total thyroidectomy.
INDICATIONS FOR THE SURGERY: Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.
HOSPITAL COURSE: The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period. On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs. She required intravenous narcotics for pain control. She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control. The wound was clean and dry. The drain was removed. She was instructed to follow up in the surgical office within one week after discharge. She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.
Keywords:
discharge summary, nodular, symptomatic thyroid goiter, thyroidectomy, goiter,
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Sample Type / Medical Specialty: General Medicine
Sample Name: Anemia - Consult
Description: Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.
(Medical Transcription Sample Report)
DIAGNOSIS: Refractory anemia that is transfusion dependent.
CHIEF COMPLAINT: I needed a blood transfusion.
HISTORY: The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.
PAST MEDICAL HISTORY: Diabetes.
PAST SURGICAL HISTORY: Hernia repair.
ALLERGIES: He has no allergies.
MEDICATIONS: Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.
SOCIAL HISTORY: He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.
FAMILY HISTORY: Negative for blood or cancer disorders according to the patient.
PHYSICAL EXAMINATION:
GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.
VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.
HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.
NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.
CHEST: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.
EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.
NEUROLOGIC: Noncontributory.
DERMATOLOGIC: Noncontributory.
CARDIOVASCULAR: Noncontributory.
IMPRESSION: At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.
RECOMMENDATIONS: At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.
As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.
Keywords:
general medicine, electrophoresis, ldh, b12, folate, erythropoietin level, reticulocyte count, serum protein, blood transfusion, bone marrow, refractory anemia, anemia, myalgias, marrow, bone,
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... | train/11_20210604143808_Hayden |
Sample Type/Medical Specialty :
General Medicine
Sample Name : Normal
Female ROS
Template Description :
Normal female review of systems template .
Negative for fever , weight change , fatigue , or aching . ( Medical Transcription Sample Report )
CONSTITUTIONAL : Normal ; negative for fever , weight change , fatigue , or aching .
HEENT : Eyes normal ; Negative for glasses , cataracts , glaucoma , retinopathy , irritation , or visual field defects . Ears normal ; Negative for hearing or balance problems . Nose normal ; Negative for runny nose , sinus problems , or nosebleeds . Mouth normal ; Negative for dental problems , dentures , or bleeding gums . Throat normal ; Negative for hoarseness , difficulty swallowing , or sore throat .
CARDIOVASCULAR : Normal ; Negative for angina , previous MI , irregular heartbeat , heart murmurs , bad heart valves , palpitations , swelling of feet , high blood pressure , orthopnea , paroxysmal nocturnal dyspnea , or history of stress test , arteriogram , or pacemaker implantation .
PULMONARY : Normal ; Negative for cough , sputum , shortness of breath , wheezing , asthma , or emphysema .
GASTROINTESTINAL : Normal ; Negative for pain , vomiting , heartburn , peptic ulcer disease , change in stool , rectal pain , hernia , hepatitis , gallbladder disease , hemorrhoids , or bleeding .
GENITOURINARY : Normal female OR male ; Negative for incontinence , UTI , dysuria , hematuria , vaginal discharge , abnormal bleeding , breast lumps , nipple discharge , skin or nipple changes , sexually transmitted diseases , incontinence , yeast infections , or itching .
SKIN : Normal ; Negative for rashes , keratoses , skin cancers , or acne .
MUSCULOSKELETAL : Normal ; Negative for back pain , joint pain , joint swelling , arthritis , joint deformity , problems with ambulation , stiffness , osteoporosis , or injuries .
NEUROLOGIC : Normal ; Negative for blackouts , headaches , seizures , stroke , or dizziness .
PSYCHIATRIC : Normal ; Negative for anxiety , depression , or phobias .
ENDOCRINE : Normal ; Negative for diabetes , thyroid , or problems with cholesterol or hormones .
HEMATOLOGIC/LYMPHATIC : Normal ; Negative for anemia , swollen glands , or blood disorders .
IMMUNOLOGIC : Negative ; Negative for steroids , chemotherapy , or cancer .
VASCULAR : Normal ; Negative for varicose veins , blood clots , atherosclerosis , or leg ulcers .
Keywords : general medicine , cough , sputum , shortness of breath , fever , weight , fatigue , aching , nose , throat , swelling , disease , incontinence , bleeding , heartbeat , blood , joint , | [
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Neonatal Discharge Summary - 1
Description: Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSES: Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.
HISTORY OF PRESENTING ILLNESS: The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. Baby was born at ABCD Hospital at 1333 on 07/14/2006. Mother is a 20-year-old gravida 1, para 0 female who received prenatal care. Prenatal course was complicated by low amniotic fluid index and hypertension. She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status. Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital. Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.
HOSPITAL COURSE: At the time of transfer to ABCD, these were the following issues.
FEEDING AND NUTRITION: Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h. Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention. The p.o. feeds were held and IV D10 water was given. Baby was started on Mylicon drops and glycerin suppositories. Abdominal ultrasound showed gaseous distention without signs of obstruction. OG tube was passed. Baby improved after couple of days when p.o. feedings were restarted. Baby was also given Reglan. At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure. Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.
RESPIRATIONS: At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.
HYPOGLYCEMIA: Baby began to experience hypoglycemic episodes on 07/24/2006. Blood glucose level was as low as 46. D10 was given initially as bolus. Baby continued to experience hypoglycemic episodes. Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level. The baby improved with diazoxide, hypoglycemic issues resolved and then began again. Diazoxide was discontinued, but the hypoglycemic issues restarted. The Diazoxide was restarted again. Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued. At the time of discharge, blood glucose levels were not being stable for 24 hours.
CARDIOVASCULAR: Infant was hemodynamically stable on admission from Madera. Infant has a closed PDA. Infant had two cardiac echograms done. The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.
CNS: Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage. The ultrasound was negative for intracranial hemorrhage.
INFECTIOUS DISEASE: The patient had been on antibiotics during the stay at Madera. At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.
HEMATOLOGY: The patient is status post phototherapy at Madera and was started on iron.
OPHTHALMOLOGY: Exam on 07/17/2006 showed immature retina. The patient is to get followup exam after discharge.
DISCHARGE DIAGNOSIS: Stable ex-32-weeks preemie.
DISCHARGE INSTRUCTIONS: The patient has been educated on CPR measures. Followup appointment has been made at Kid's Care. Calcium challenge has been done. The patient's parents are comfortable with feeding. The patient has been discharged on NeoSure and expressed breast milk.
Keywords:
discharge summary, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant,
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Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Female ROS Template
Description: Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.
(Medical Transcription Sample Report)
CONSTITUTIONAL: Normal; negative for fever, weight change, fatigue, or aching.
HEENT: Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. Ears normal; Negative for hearing or balance problems. Nose normal; Negative for runny nose, sinus problems, or nosebleeds. Mouth normal; Negative for dental problems, dentures, or bleeding gums. Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.
CARDIOVASCULAR: Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.
PULMONARY: Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.
GASTROINTESTINAL: Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.
GENITOURINARY: Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.
SKIN: Normal; Negative for rashes, keratoses, skin cancers, or acne.
MUSCULOSKELETAL: Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.
NEUROLOGIC: Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.
PSYCHIATRIC: Normal; Negative for anxiety, depression, or phobias.
ENDOCRINE: Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.
HEMATOLOGIC/LYMPHATIC: Normal; Negative for anemia, swollen glands, or blood disorders.
IMMUNOLOGIC: Negative; Negative for steroids, chemotherapy, or cancer.
VASCULAR: Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.
Keywords:
general medicine, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint,
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Neck Pain - Discharge Summary
Description: Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSES
1. Neck pain with right upper extremity radiculopathy.
2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
DISCHARGE DIAGNOSES
1. Neck pain with right upper extremity radiculopathy.
2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
OPERATIVE PROCEDURES
1. Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.
2. Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.
3. Spinal instrumentation C4 through C7.
4. Implant.
5. Allograft.
COMPLICATIONS: None.
COURSE ON ADMISSION: This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand. The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now. The patient has been treated with medications, which has been unrelenting. The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7. The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine. The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger. The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol. The patient will have continued pain medication coverage with Darvocet and Flexeril. The patient will follow up with me as scheduled. Instructions have been given.
Keywords:
discharge summary, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,
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Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 4
Description: An example/template for a routine normal male physical exam.
(Medical Transcription Sample Report)
VITAL SIGNS: Blood pressure *, pulse *, respirations *, temperature *.
GENERAL APPEARANCE: Alert and in no apparent distress, calm, cooperative, and communicative.
HEENT: Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. No papilledema, glaucoma, or cataracts. Ears: Normal set and shape with normal hearing and normal TMs. Nose and Sinus: Unremarkable. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.
NECK: Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy. Trachea is midline without stridor, shift, or subcutaneous emphysema. Thyroid is palpable, nontender, not enlarged, and free of nodularity.
CHEST: Lungs bilaterally clear to auscultation and percussion.
HEART: S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI is nondisplaced. Chest wall is unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected.
BREASTS: Normal male breast tissue.
ABDOMEN: No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and intraabdominal bruit on auscultation.
EXTERNAL GENITALIA: Normal for age. Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.
RECTAL: Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness. No rectal masses palpated.
EXTREMITIES: Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints.
BACK: Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs.
NEUROLOGIC: Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable.
SKIN: Unremarkable for any premalignant or malignant condition with normal changes for age.
Keywords:
general medicine, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue,
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Sample Type / Medical Specialty: General Medicine
Sample Name: Air Under Diaphragm - Consult
Description: Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Possible free air under the diaphragm.
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.
PAST MEDICAL HISTORY: Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.
PAST SURGICAL HISTORY: Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.
MEDICATIONS: Unable to evaluate.
ALLERGIES: UNABLE TO EVALUATE.
SOCIAL HISTORY: Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.
REVIEW OF SYSTEMS: Unable to obtain.
PHYSICAL EXAM
VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.
GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.
HEENT: Atraumatic.
NECK: Soft and supple.
LUNGS: Bilaterally diminished.
HEART: Regular.
ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.
LABORATORY STUDIES: Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.
X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.
ASSESSMENT: No intra-abdominal pathology.
PLAN: Have her admitted to the medical service for treatment of her hyponatremia.
Keywords:
general medicine, free air, hyponatremia, air under the diaphragm, intra abdominal pathology, abdominal, pathology, obtunded, diaphragm,
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"c... | train/147_20210112211713 |
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