text stringlengths 1.18k 7.92k | tokens listlengths 231 1.55k | entity listlengths 19 367 | filename stringlengths 15 30 |
|---|---|---|---|
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Disseminated",
"Intravascular",
"Coagulation",
"\n",
"Description",
":",
"Disseminated",
"intravascular",
"coagulation",
"and",
"Streptococcal",
"pneumonia",
"with... | [
{
"char_end": 101,
"char_start": 63,
"text": "Disseminated Intravascular Coagulation",
"token_end": 15,
"token_start": 12,
"type": "problem"
},
{
"char_end": 153,
"char_start": 115,
"text": "Disseminated intravascular coagulation",
"token_end": 21,
"token_start": 18,
... | 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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Speech",
"Therapy",
"-",
"Discharge",
"Summary",
"-",
"2",
"\n",
"Description",
":",
"The",
"patient",
"was",
"referred",
"for",
"outpatient",
"skilled",
... | [
{
"char_end": 178,
"char_start": 145,
"text": "outpatient skilled speech therapy",
"token_end": 31,
"token_start": 27,
"type": "treatment"
},
{
"char_end": 218,
"char_start": 193,
"text": "right hemisphere disorder",
"token_end": 37,
"token_start": 34,
"type": "pr... | train/108_20210112211708 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Death",
"Summary",
"-",
"1",
"\n",
"Description",
":",
"Death",
"summary",
"of",
"patient",
"with",
"advanced",
"non",
"-",
"small",
"cell",
"lung",
"... | [
{
"char_end": 163,
"char_start": 134,
"text": "non-small cell lung carcinoma",
"token_end": 31,
"token_start": 25,
"type": "problem"
},
{
"char_end": 153,
"char_start": 149,
"text": "lung",
"token_end": 30,
"token_start": 29,
"type": "bodyloc"
},
{
"char_e... | train/115_20210112211709 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Post",
"Thyroidectomy",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Symptomatic",
"thyroid",
"goiter",
".",
"Total",
"thyroidectomy",
".",
"\n",... | [
{
"char_end": 82,
"char_start": 69,
"text": "Thyroidectomy",
"token_end": 14,
"token_start": 13,
"type": "treatment"
},
{
"char_end": 142,
"char_start": 116,
"text": "Symptomatic thyroid goiter",
"token_end": 23,
"token_start": 20,
"type": "problem"
},
{
"... | train/116_20210112211709 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Anemia",
"-",
"Consult",
"\n",
"Description",
":",
"Refractory",
"anemia",
"that",
"is",
"transfusion",
"dependent",
".",
"At",
"this",
"time",
",",
"he"... | [
{
"char_end": 69,
"char_start": 63,
"text": "Anemia",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 110,
"char_start": 93,
"text": "Refractory anemia",
"token_end": 20,
"token_start": 18,
"type": "problem"
},
{
"char_end": 140,
... | 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 , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"\n",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"\n",
"Female",
"ROS",
"\n",
"Template",
"Description",
":",
"\n",
"Normal",
"female",
"review",
"of",
"systems",
"template",
".",
"\n ",
... | [
{
"char_end": 161,
"char_start": 153,
"text": "Negative",
"token_end": 31,
"token_start": 30,
"type": "negation"
},
{
"char_end": 171,
"char_start": 166,
"text": "fever",
"token_end": 33,
"token_start": 32,
"type": "problem"
},
{
"char_end": 187,
"char... | train/11_20210610044406_Isra |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Neonatal",
"Discharge",
"Summary",
"-",
"1",
"\n",
"Description",
":",
"Respiratory",
"distress",
"syndrome",
",",
"intrauterine",
"growth",
"restriction",
... | [
{
"char_end": 137,
"char_start": 108,
"text": "Respiratory distress syndrome",
"token_end": 23,
"token_start": 20,
"type": "problem"
},
{
"char_end": 170,
"char_start": 139,
"text": "intrauterine growth restriction",
"token_end": 27,
"token_start": 24,
"type": "pr... | train/128_20210112211711 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Female",
"ROS",
"Template",
"\n",
"Description",
":",
"Normal",
"female",
"review",
"of",
"systems",
"template",
".",
"Negative",
"for",
"fever",... | [
{
"char_end": 153,
"char_start": 145,
"text": "Negative",
"token_end": 27,
"token_start": 26,
"type": "negation"
},
{
"char_end": 163,
"char_start": 158,
"text": "fever",
"token_end": 29,
"token_start": 28,
"type": "problem"
},
{
"char_end": 178,
"char... | train/134_20210112211711 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Neck",
"Pain",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Neck",
"pain",
"with",
"right",
"upper",
"extremity",
"radiculopathy",
"and",
"cerv... | [
{
"char_end": 73,
"char_start": 64,
"text": "Neck Pain",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 68,
"char_start": 64,
"text": "Neck",
"token_end": 13,
"token_start": 12,
"type": "bodyloc"
},
{
"char_end": 116,
"char_star... | train/138_20210112211712 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Male",
"Exam",
"Template",
"-",
"4",
"\n",
"Description",
":",
"An",
"example",
"/",
"template",
"for",
"a",
"routine",
"normal",
"male",
"ph... | [
{
"char_end": 165,
"char_start": 130,
"text": "a routine normal male physical exam",
"token_end": 32,
"token_start": 26,
"type": "test"
},
{
"char_end": 216,
"char_start": 205,
"text": "VITAL SIGNS",
"token_end": 43,
"token_start": 41,
"type": "test"
},
{
... | train/141_20210112211712 |
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,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Air",
"Under",
"Diaphragm",
"-",
"Consult",
"\n",
"Description",
":",
"Possible",
"free",
"air",
"under",
"the",
"diaphragm",
".",
"On",
"a",
"chest",
... | [
{
"char_end": 114,
"char_start": 106,
"text": "Possible",
"token_end": 21,
"token_start": 20,
"type": "uncertain"
},
{
"char_end": 143,
"char_start": 115,
"text": "free air under the diaphragm",
"token_end": 26,
"token_start": 21,
"type": "problem"
},
{
"c... | train/147_20210112211713 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 46
Description: Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.
(Medical Transcription Sample Report)
DIAGNOSES:
1. Pneumonia.
2. Crohn disease.
3. Anasarca.
4. Anemia.
CHIEF COMPLAINT: I have a lot of swelling in my legs.
HISTORY: The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months. He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers. This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital. He has been treated with IV antibiotics and is growing Streptococcus. At this time, he seems relatively stable although slightly dyspneic. Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities. At this time, he continues to have symptoms consistent with diarrhea and malabsorption. He also has some episodes of nausea and vomiting at times. He currently has a cough and symptoms of dyspnea. Further review of systems was not otherwise contributory.
MEDICATIONS:
1. Prednisone.
2. Effexor.
3. Folic acid.
4. Norco for pain.
PAST MEDICAL HISTORY: As mentioned above, but he also has anxiety and depression.
PAST SURGICAL HISTORY:
1. Small bowel resections.
2. Appendectomy.
3. A vasectomy.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.
FAMILY HISTORY: Significant for his father who died of IPF and irritable bowel syndrome.
REVIEW OF SYSTEMS: As mentioned in the history of present illness and further review of systems is not otherwise contributory.
PHYSICAL EXAMINATION:
GENERAL: He is a thin appearing man in very mild respiratory distress when his oxygen is off.
VITAL SIGNS: His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.
HEENT: Sclerae anicteric. Conjunctivae normal. Nasal and oropharynx are clear.
NECK: Supple. No jugular venous pressure distention is noted. There is no adenopathy in the cervical, supraclavicular or axillary areas.
CHEST: Reveals some crackles in the right chest, in the base, and in the upper lung fields. His left is relatively clear with decreased breath sounds.
HEART: Regular rate and rhythm.
ABDOMEN: Slightly protuberant. Bowel sounds are present. He is slightly tender and it is diffuse. There is no organomegaly and no ascites appreciable.
EXTREMITIES: There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.
DERMATOLOGIC: Shows thin skin. No ecchymosis or petechiae.
LABORATORY STUDIES: Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3. There is no M-spike observed. His B12 is 500 with a folic acid of 11. His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.
IMPRESSION AT THIS TIME:
1. Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.
2. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.
ASSESSMENT AND PLAN: At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate. I believe that he needs a calorie count. We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered. I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist. I will help in anyway that I can to improve the patient's laboratory abnormalities. However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time. I have explained this in detail to the patient and his family. Everybody expresses understanding and all questions were answered. At this time, follow him up during his hospital stay and plan to see him in the office as well.
Keywords:
general medicine, anasarca, anemia, diarrhea, crampy, enteropathy, malnutrition, lower extremity edema, folic acid, crohn disease, pneumonia,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"46",
"\n",
"Description",
":",
"Pneumonia",
"in",
"the",
"face",
"of",
"fairly",
"severe",
"Crohn",
"disease",
"with",
"p... | [
{
"char_end": 106,
"char_start": 97,
"text": "Pneumonia",
"token_end": 21,
"token_start": 20,
"type": "problem"
},
{
"char_end": 149,
"char_start": 122,
"text": "fairly severe Crohn disease",
"token_end": 29,
"token_start": 25,
"type": "problem"
},
{
"char... | train/14_20210604143809_Hayden |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: D&C - Discharge Summary
Description: Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSES:
1. Severe menometrorrhagia unresponsive to medical therapy.
2. Severe anemia.
3. Fibroid uterus.
DISCHARGE DIAGNOSES:
1. Severe menometrorrhagia unresponsive to medical therapy.
2. Severe anemia.
3. Fibroid uterus.
OPERATIONS PERFORMED:
1. Hysteroscopy.
2. Dilatation and curettage (D&C).
3. Myomectomy.
COMPLICATIONS: Large endometrial cavity fibroid requiring careful dissection and excision.
BLOOD TRANSFUSIONS: Two units of packed red blood cells.
INFECTION: None.
SIGNIFICANT LAB AND X-RAY: Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.
HOSPITAL COURSE AND TREATMENT: The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed. Hysteroscopy revealed a large endometrial cavity fibroid. Careful shaving and excision of this fibroid was performed with removal of the fibroid. Hemostasis was noted completely at the end of this procedure. Postoperatively, the patient has done well. The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss. The patient is now ambulating without difficulty and tolerating her diet. The patient desires to go home. The patient is discharged to home.
DISCHARGE CONDITION: Stable.
DISCHARGE INSTRUCTIONS: Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks. Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate tablets 1 tablet p.o. daily. Ambulate with assistance at home only. The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care. The patient was given full and complete postop and discharge instructions. All her questions were answered.
Keywords:
discharge summary, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"D",
"&",
"C",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Hysteroscopy",
",",
"dilatation",
"and",
"curettage",
"(",
"D",
"&",
"C",
")",
... | [
{
"char_end": 67,
"char_start": 64,
"text": "D&C",
"token_end": 15,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 113,
"char_start": 101,
"text": "Hysteroscopy",
"token_end": 22,
"token_start": 21,
"type": "test"
},
{
"char_end": 145,
"char_s... | train/152_20210112211713 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Sepsis - Consult
Description: Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.
(Medical Transcription Sample Report)
REASON FOR ADMISSION: Sepsis.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. The patient is unable to provide further history. The patient's son is at the bedside and confirmed his history. The patient was given IV antibiotics in the emergency room. He was also given some hydration.
PAST MEDICAL HISTORY:
1. History of CAD.
2. History of dementia.
3. History of CVA.
4. History of nephrolithiasis.
ALLERGIES: NONE.
MEDICATIONS:
1. Ambien.
2. Milk of magnesia.
3. Tylenol.
4. Tramadol.
5. Soma.
6. Coumadin.
7. Zoloft.
8. Allopurinol.
9. Digoxin.
10. Namenda.
11. Zocor.
12. BuSpar.
13. Detrol.
14. Coreg.
15. Colace.
16. Calcium.
17. Zantac.
18. Lasix.
19. Seroquel.
20. Aldactone.
21. Amoxicillin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives in a board and care. No tobacco, alcohol or IV drug use.
REVIEW OF SYSTEMS: As per the history of present illness, otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile. Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.
GENERAL: The patient is awake. Not oriented x3, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are dry.
NECK: Supple. No thyromegaly. No jugular venous distention.
HEART: Irregularly irregular, brady.
LUNGS: Clear to auscultation bilaterally anteriorly.
ABDOMEN: Positive normoactive bowel sounds. Soft. Tenderness in the suprapubic region without rebound.
EXTREMITIES: No clubbing, cyanosis or edema in upper and lower extremities.
NEUROLOGIC: As mentioned above. No focality is noted.
LABORATORY STUDIES: CT of the abdomen shows left inguinal hernia with greater than 10 cm of colon in sac, no SBO, dilated bladder with thick wall, possible outlet obstruction, bilateral hydronephrosis and hydroureter, and 2.7 cm right adrenal gland mass.
White count 30.8, hemoglobin 10.9, and platelet count 413. UA shows greater than 100 WBCs, greater than 100 RBCs with 500 leukocyte esterase. Sodium 149, potassium 4.1, chloride 116, CO2 19, BUN 89, and creatinine 2.1.
EKG shows atrial fibrillation at a very slow rate of 55.
PROBLEM LIST:
1. Urinary tract infection with sepsis.
2. Obstructive uropathy.
3. Dementia.
4: Atrial fibrillation.
5. Anemia.
6. Adrenal gland mass.
RECOMMENDATIONS:
1. Obtain urology consult with Dr. X.
2. Obtain renal consult Dr. Y.
3. Place the patient on Levaquin renally dosed.
4. Give one dose of gentamicin for synergy n the urine.
5. IV fluids with hypertonic-hypotonic.
6. Hold anticoagulation and put the patient on SCD and TED hose bilateral lower extremities.
7. The patient is currently in slow atrial fibrillation. Hold all rate control medications and check digoxin level.
8. Continue dementia medications.
9. PPI for PUD prophylaxis.
Keywords:
general medicine, abdominal pain, hydronephrosis, hydroureter, urology, urinary tract infection with sepsis, ct scan, adrenal gland, dilated bladder, bilateral hydronephrosis, atrial fibrillation, sepsis,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Sepsis",
"-",
"Consult",
"\n",
"Description",
":",
"Sepsis",
".",
"The",
"patient",
"was",
"found",
"to",
"have",
"a",
"CT",
"scan",
"with",
"dilated",... | [
{
"char_end": 69,
"char_start": 63,
"text": "Sepsis",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 99,
"char_start": 93,
"text": "Sepsis",
"token_end": 19,
"token_start": 18,
"type": "problem"
},
{
"char_end": 140,
"char_start... | train/155_20210112211713 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 17
Description: The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved.
(Medical Transcription Sample Report)
FINAL DIAGNOSIS/REASON FOR ADMISSION:
1. Acute right lobar pneumonia.
2. Hypoxemia and hypotension secondary to acute right lobar pneumonia.
3. Electrolyte abnormality with hyponatremia and hypokalemia - corrected.
4. Elevated liver function tests, etiology undetermined.
5. The patient has a history of moderate-to-severe dementia, Alzheimer's type.
6. Anemia secondary to current illness and possible iron deficiency.
7. Darkened mole on the scalp, status post skin biopsy, pending pathology report.
OPERATION AND PROCEDURE: The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009. Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic. Dr. Y's results pending.
DISPOSITION: The patient discharged to long-term acute facility under the care of Dr. Z.
CONDITION ON DISCHARGE: Clinically improved, however, requiring acute care.
CURRENT MEDICATIONS: Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.
HOSPITAL SUMMARY: This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough. Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate. She was started on antibiotics. Infectious Disease was consulted. She was initially begun on vancomycin. Blood, sputum, and urine cultures were obtained; the results of which were negative for infection. She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis. During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning. Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour. She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment. Due to some elevated liver function tests, she was seen in consultation by Dr. X. An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder. A HIDA scan was performed and revealed no evidence of gallbladder dysfunction. Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value. She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics. Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%. She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.
LABORATORY TESTS: Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay. Blood cultures were negative at 5 days. Sputum culture was negative. Urine culture was negative and thoracentesis culture negative at 24 hours. The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained. Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8. Her PT and PTT were normal. Occult blood studies were negative for occult blood. Hepatitis B antigen was negative. Hepatitis A antibody IgM was negative. Hepatitis B core IgM negative, and hepatitis C core antibody was negative. At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.
At the time of discharge, the patient had improved. She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.
Keywords:
discharge summary, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"17",
"\n",
"Description",
":",
"The",
"patient",
"underwent",
"a",
"scalp",
"skin",
"biopsy",
"with",
"pathology",
"specimen"... | [
{
"char_end": 141,
"char_start": 122,
"text": "a scalp skin biopsy",
"token_end": 26,
"token_start": 22,
"type": "test"
},
{
"char_end": 165,
"char_start": 147,
"text": "pathology specimen",
"token_end": 29,
"token_start": 27,
"type": "test"
},
{
"char_end... | train/163_20210112211715 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 7
Description: Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Right-sided facial droop and right-sided weakness.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation. While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop. The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.
ALLERGIES: SHE IS ALLERGIC TO PENICILLIN.
SOCIAL HISTORY: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.
FAMILY HISTORY: Noncontributory.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident with expressive aphasia and lower extremity weakness.
2. Abnormality of gait and wheelchair bound secondary to #1.
3. Hypertension.
4. Chronic obstructive pulmonary disease, on nasal oxygen.
5. Anxiety disorder.
6. Dementia.
PAST SURGICAL HISTORY: Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.
REVIEW OF SYSTEMS: Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.
PHYSICAL EXAMINATION:
GENERAL: She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.
VITAL SIGNS: Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.
HEENT: Pupils are equal, round, and reactive to light. External ocular muscles are intact. Conjunctivae anicteric. There is a slight right-sided facial droop. Oropharynx is clear with the missing teeth on the upper and the lower part. Tympanic membranes are clear.
NECK: Supple. There is no carotid bruit. No cervical adenopathy.
CARDIAC: Regular rate and rhythm with 2/6 systolic murmur, more at the apex.
LUNGS: Clear to auscultation.
ABDOMEN: Soft and no tenderness. Bowel sound is present.
EXTREMITIES: There is no pedal edema. Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.
NEUROLOGIC: There is right-sided slight facial droop. She moves both upper extremities equally. She has withdrawal of both lower extremities by touching her sole of the feet.
SKIN: There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.
LABORATORY DATA: The CT scan of the head shows brain atrophy with no acute events. Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92. Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000. The urinalysis was more than 100 white blood cells and 10-25 red blood cells. Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.
ASSESSMENT:
1. Recent cerebrovascular accident with right-sided weakness.
2. Hypertension.
3. Dementia.
4. Anxiety.
5. Urinary tract infection.
6. Abnormality of gait secondary to lower extremity weakness.
PLAN: We will keep the patient NPO until a swallowing evaluation was done. We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170. Neuro check every 4 hours for 24 hours. We will start her on amikacin IV per pharmacy. We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done. Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n. I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.
Keywords:
general medicine, hypertension, right-sided weakness, facial droop, wheelchair bound, blood pressure, swallowing evaluation, cerebrovascular accident, weakness,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"7",
"\n",
"Description",
":",
"Right",
"-",
"sided",
"facial",
"droop",
"and",
"right",
"-",
"sided",
"weakness",
".",
... | [
{
"char_end": 120,
"char_start": 96,
"text": "Right-sided facial droop",
"token_end": 25,
"token_start": 20,
"type": "problem"
},
{
"char_end": 114,
"char_start": 96,
"text": "Right-sided facial",
"token_end": 24,
"token_start": 20,
"type": "bodyloc"
},
{
... | train/167_20210112211715 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Hypertension & Cardiomyopathy
Description: Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.
(Medical Transcription Sample Report)
PROBLEMS LIST:
1. Nonischemic cardiomyopathy.
2. Branch vessel coronary artery disease.
3. Congestive heart failure, NYHA Class III.
4. History of nonsustained ventricular tachycardia.
5. Hypertension.
6. Hepatitis C.
INTERVAL HISTORY: The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications. However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest. He has history of orthopnea and PND. He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.
REVIEW OF SYSTEMS: Positive for right upper quadrant pain. He has occasional nausea, but no vomiting. His appetite has decreased. No joint pain, TIA, seizure or syncope. Other review of systems is unremarkable.
I reviewed his past medical history, past surgical history, and family history.
SOCIAL HISTORY: He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.
ALLERGIES: He has no known drug allergies.
MEDICATIONS: I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07. HEENT: Atraumatic and normocephalic. No pallor, icterus or cyanosis. NECK: Supple. Jugular venous distention 5 cm above the clavicle present. No thyromegaly. LUNGS: Clear to auscultation. No rales or rhonchi. Pulse ox was 98% on room air. CVS: S1 and S2 present. S3 and S4 present. ABDOMEN: Soft and nontender. Liver is palpable 5 cm below the right subcostal margin. EXTREMITIES: No clubbing or cyanosis. A 1+ edema present.
ASSESSMENT AND PLAN: The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease. Clinically, he is in NYHA Class III. He has some volume overload and was not unfortunately taking Lasix as prescribed. I have advised him to take Lasix 40 mg p.o. b.i.d. I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d. I advised him to continue to take Toprol and lisinopril. I have also added Aldactone 25 mg p.o. daily for survival advantage. I reinforced the idea of not using cocaine. He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine. I encouraged him to find a primary care provider. He will come for a BMP check in one week. I asked him to check his blood pressure and weight. I discussed medication changes and gave him an updated list. I have asked him to see a gastroenterologist for hepatitis C. At this point, his Medicaid is pending. He has no insurance and finds hard to find a primary care provider. I will see him in one month. He will have his fasting lipid profile, AST, and ALT checked in one week.
Keywords:
general medicine, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Hypertension",
"&",
"Cardiomyopathy",
"\n",
"Description",
":",
"Nonischemic",
"cardiomyopathy",
",",
"branch",
"vessel",
"coronary",
"artery",
"disease",
",",... | [
{
"char_end": 75,
"char_start": 63,
"text": "Hypertension",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 92,
"char_start": 78,
"text": "Cardiomyopathy",
"token_end": 15,
"token_start": 14,
"type": "problem"
},
{
"char_end": 132,
... | train/171_20210112211716 |
Sample Type/Medical Specialty : General Medicine
Sample Name : Gen Med Consult - 49
Description :
A female with a past medical history of chronic kidney disease , stage 4; history of diabetes mellitus ; diabetic nephropathy ; peripheral vascular disease , status post recent PTA of right leg , admitted to the hospital because of swelling of the right hand and left foot . ( Medical Transcription Sample Report ) HISTORY OF PRESENT ILLNESS : This is a 70-year-old female with a past medical history of chronic kidney disease , stage 4 ; history of diabetes mellitus ; diabetic nephropathy ; peripheral vascular disease , status post recent PTA of right leg , admitted to the hospital because of swelling of the right hand and left foot . The patient says that the right hand was very swollen , very painful , could not move the fingers , and also , the left foot was very swollen and very painful , and again could not move the toes , came to emergency room , diagnosed with gout and gouty attacks . I was asked to see the patient regarding chronic kidney disease .
PAST MEDICAL HISTORY :
1 . Diabetes mellitus type 2.
2 . Diabetic nephropathy.
3 . Chronic kidney disease, stage 4.
4 . Hypertension.
5 . Hypercholesterolemia and hyperlipidemia.
6 . Peripheral vascular disease, status post recent, last week PTA of right lower extremity .
SOCIAL HISTORY :
Negative for smoking and drinking .
CURRENT HOME MEDICATIONS :
NovoLog 20 units with each meal , Lantus 30 units at bedtime , Crestor 10 mg daily , Micardis 80 mg daily , Imdur 30 mg daily , Amlodipine 10 mg daily , Coreg 12.5 mg b.i.d. , Lasix 20 mg daily , Ecotrin 325 mg daily , and calcitriol 0.5 mcg daily .
REVIEW OF SYSTEMS :
The patient denies any complaints , states that the right hand and left foot was very swollen and very painful , and came to emergency room . Also , she could not urinate and states as soon as they put Foley in , 500 mL of urine came out . Also they started her on steroids and colchicine , and the pain is improving and the swelling is getting better . Denies any fever and chills . Denies any dysuria , frequency or hematuria . States that the urine output was decreased considerably , and she could not urinate . Denies any cough , hemoptysis or sputum production . Denies any chest pain , orthopnea or paroxysmal nocturnal dyspnea .
PHYSICAL EXAMINATION :
General : The patient is alert and oriented , in no acute distress .
Vital Signs : Blood pressure 126/67 , temperature 97.9 , pulse 71 , and respirations 20. The patient's weight is 105.6 kg .
Head : Normocephalic .
Neck : Supple . No JVD . No adenopathy .
Chest : Symmetric . No retractions .
Lungs : Clear .
Heart : RRR with no murmur .
Abdomen : Obese , soft , and nontender . No rebound . No guarding .
Extremity : She has 2+ pretibial edema bilaterally at the lower extremity , but also the left foot , in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities .
LAB TESTS :
Showed that urine culture is negative up to date . The patient's white cell is 12.7 , hematocrit 26.1 . The patient has 90% segs and 0% bands . Serum sodium 133 , potassium 5.9 , chloride 100 , bicarb 21 , glucose 348 , BUN 57 , creatinine is 2.39 , calcium 8.9 , and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells , 3+ protein , 3+ blood with 25 to 30 red blood cells also.
IMPRESSION :
1 . Urinary tract infection .
2 . Acute gouty attack .
3 . Diabetes mellitus with diabetic nephropathy .
4 . Hypertension .
5 . Hypercholesterolemia .
6 . Peripheral vascular disease , status post recent PTA in the right side .
7 . Chronic kidney disease , stage 4.
PLAN :
At this time is I agree with treatment . We will add allopurinol 50 mg daily . This is secondary to the patient is already on colchicine , and also we will discontinue Micardis , we will increase Lasix to 40 b.i.d . , and we will follow with the lab results .
Keywords : general medicine , hypertension , hypercholesterolemia , hyperlipidemia , pta , gouty attack , urinary tract infection , peripheral vascular disease , chronic kidney disease , diabetes mellitus , diabetic nephropathy , disease , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"49",
"\n",
"Description",
":",
"\n",
"A",
"female",
"with",
"a",
"past",
"medical",
"history",
"of",
"chronic",
"kidney",... | [
{
"char_end": 173,
"char_start": 141,
"text": "chronic kidney disease , stage 4",
"token_end": 35,
"token_start": 29,
"type": "problem"
},
{
"char_end": 148,
"char_start": 141,
"text": "chronic",
"token_end": 30,
"token_start": 29,
"type": "course"
},
{
"c... | train/17_20210610044407_Isra |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Laryngitis - Discharge
Description: Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.
(Medical Transcription Sample Report)
DIAGNOSIS: Chronic laryngitis, hoarseness.
HISTORY: The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".
SHORT-TERM GOALS:
1. To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.
2. He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.
3. We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.
4. To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.
LONG-TERM GOALS:
1. The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.
2. The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.
The patient is discharged from my services at this time with a home program to continue to promote normal voicing.
Keywords:
discharge summary, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Laryngitis",
"-",
"Discharge",
"\n",
"Description",
":",
"Chronic",
"laryngitis",
",",
"hoarseness",
".",
"The",
"patient",
"was",
"referred",
"to",
"Medi... | [
{
"char_end": 74,
"char_start": 64,
"text": "Laryngitis",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 118,
"char_start": 100,
"text": "Chronic laryngitis",
"token_end": 20,
"token_start": 18,
"type": "problem"
},
{
"char_end": 13... | train/20_20210604143811_Hayden |
Sample Type/Medical Specialty : General Medicine
Sample Name : Nausea & Vomiting
- ER Visit Description :
She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days . This is patient's fourth trip to the emergency room and second trip for admission . ( Medical Transcription Sample Report )
HISTORY OF PRESENT ILLNESS :
She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days . This is patient's fourth trip to the emergency room and second trip for admission .
PAST MEDICAL HISTORY : Nonsignificant .
PAST SURGICAL HISTORY : None .
SOCIAL HISTORY : No alcohol , drugs , or tobacco .
PAST OBSTETRICAL HISTORY : This is her first pregnancy .
PAST GYNECOLOGICAL HISTORY : Not pertinent . While in the emergency room , the patient was found to have slight low sodium , potassium slightly elevated and her ALT of 93 , AST of 35 , total bilirubin is 1.2 . Her urine was 3+ ketones , 2+ protein , and 1+ esterase , and rbc too numerous to count with moderate amount of bacteria . H and H stable at 14.1 and 48.7 . She was then admitted after giving some Phenergan and Zofran IV . As started on IV , given hydration as well as given a dose of Rocephin to treat bladder infection . She was admitted overnight , nausea and vomiting resolved to only one episode of vomiting after receiving Maalox , tolerated fluids as well as p.o. food .
Followup chemistry was obtained for AST , ALT and we will plan for discharge if lab variables resolve .
ASSESSMENT AND PLAN :
1 . This is a 28 - year - old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup .
2 . Slightly elevated ALT , questionable , likely due to the nausea and vomiting . We will recheck for followup .
Keywords : general medicine , iv hydration , elevated alt , emergency , nausea , vomiting , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Nausea",
"&",
"Vomiting",
"\n",
"-",
"ER",
"Visit",
"Description",
":",
"\n",
"She",
"is",
"a",
"28",
"-",
"year",
"-",
"old",
"G1",
"at",
"approxi... | [
{
"char_end": 70,
"char_start": 64,
"text": "Nausea",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 81,
"char_start": 73,
"text": "Vomiting",
"token_end": 15,
"token_start": 14,
"type": "problem"
},
{
"char_end": 197,
"char_sta... | train/21_20210610044409_Isra |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary - 1
Description: The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.
(Medical Transcription Sample Report)
HISTORY: The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery. Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.
SHORT-TERM GOALS:
1. The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration. At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present. The patient was instructed to talk to the primary care physician about removal of her feeding tube.
2. The patient will increase accuracy of yes-no responses to greater than 80% accuracy. She did accomplish this goal. The patient is also able to identify named objects with greater than 80% accuracy.
ADDITIONAL GOALS: Following the completion of these goals, additional goals were established. Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently. The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions. The patient continues to have marked difficulty with her expressive language abilities. She is able to write simple words to help express her basic wants and needs. She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions. A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4. Once again, she made significant improvement and comprehension, but continues to have unintelligible speech. An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device. If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her. Please reconsult at that time if and when the patient is ready to use a speech generating device. The patient is discharged from my services at this time due to a plateau in her progress. Numerous home activities were recommended to allow her to continue to make progress at home.
Keywords:
discharge summary, communication skills, g-tube, aphasia, language evaluation, western aphasia battery, skilled speech therapy, swallowing function, speech therapy, therapy, swallowing, aspiration, speech, communication,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Speech",
"Therapy",
"-",
"Discharge",
"Summary",
"-",
"1",
"\n",
"Description",
":",
"The",
"patient",
"was",
"referred",
"to",
"Medical",
"Center",
"'s... | [
{
"char_end": 78,
"char_start": 64,
"text": "Speech Therapy",
"token_end": 14,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 224,
"char_start": 202,
"text": "skilled speech therapy",
"token_end": 37,
"token_start": 34,
"type": "treatment"
},
{
"c... | train/23_20210604143812_Hayden |
Sample Type/Medical Specialty :
General Medicine
Sample Name : Normal Female Exam Template
- 2 Description : An example/template for a routine normal female 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 of lids , lashes , brows , or conjunctivae noted . Funduscopic examination unremarkable . Ears : Normal set , shape , TMs , canals and hearing . Nose and Sinuses : Negative . Mouth , Tongue , Teeth , and Throat : Negative except for dental work .
NECK : Supple and pain free without bruit , JVD , adenopathy or thyroid abnormality .
CHEST : Lungs are bilaterally clear to auscultation and percussion .
HEART : S1 and S2 . Regular rate and rhythm without murmur , heave , click , lift , thrill , rub , or gallop . PMI nondisplaced . Chest wall unremarkable to inspection and palpation . No axillary or supraclavicular adenopathy detected . BREASTS : In the seated and supine position unremarkable .
ABDOMEN : No hepatosplenomegaly , mass , tenderness , rebound , rigidity , or guarding . No widening of the aortic impulse and no intraabdominal bruit auscultated .
EXTERNAL GENITALIA : Normal for age .
RECTAL : Negative to 7 cm by gloved digital palpation with Hemoccult - negative stool .
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 , heent , general appearance , hepatosplenomegaly , mass , tenderness , rebound , rigidity , pulse , bruit , adenopathy , chest , percussion , inspection , palpation , signs , tongue , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"\n",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Female",
"Exam",
"Template",
"\n",
"-",
"2",
"Description",
":",
"An",
"example",
"/",
"template",
"for",
"a",
"routine",
"normal",
"fe... | [
{
"char_end": 152,
"char_start": 146,
"text": "normal",
"token_end": 30,
"token_start": 29,
"type": "labvalue"
},
{
"char_end": 173,
"char_start": 153,
"text": "female physical exam",
"token_end": 33,
"token_start": 30,
"type": "test"
},
{
"char_end": 228,... | train/23_20210610044409_Isra |
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 , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Male",
"Exam",
"Template",
"-",
"4",
"\n",
"Description",
":",
"An",
"example",
"/",
"template",
"for",
"a",
"routine",
"normal",
"male",
"ph... | [
{
"char_end": 167,
"char_start": 132,
"text": "a routine normal male physical exam",
"token_end": 32,
"token_start": 26,
"type": "test"
},
{
"char_end": 221,
"char_start": 210,
"text": "VITAL SIGNS",
"token_end": 42,
"token_start": 40,
"type": "test"
},
{
... | train/25_20210610044410_Isra |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Cognitive Linguistic Impairment - Discharge
Description: Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.
(Medical Transcription Sample Report)
DIAGNOSIS: Cognitive linguistic impairment secondary to stroke.
NUMBER OF SESSIONS COMPLETED: 5
HOSPITAL COURSE: The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.
She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge.
Keywords:
discharge summary, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Cognitive",
"Linguistic",
"Impairment",
"-",
"Discharge",
"\n",
"Description",
":",
"Cognitive",
"linguistic",
"impairment",
"secondary",
"to",
"stroke",
".",... | [
{
"char_end": 95,
"char_start": 64,
"text": "Cognitive Linguistic Impairment",
"token_end": 15,
"token_start": 12,
"type": "problem"
},
{
"char_end": 152,
"char_start": 121,
"text": "Cognitive linguistic impairment",
"token_end": 23,
"token_start": 20,
"type": "pr... | train/26_20210604143812_Hayden |
Sample Type/Medical Specialty :
Discharge Summary
Sample Name : Discharge Summary - Nephrology Description : P
atient with left renal cell carcinoma , left renal cyst , had robotic - Assisted laparoscopic left renal cyst decortication and cystoscopy . ( Medical Transcription Sample Report )
ADMITTING DIAGNOSES : Left renal cell carcinoma , left renal cyst . DISCHARGE DIAGNOSIS : Left renal cell carcinoma , left renal cyst .
SECONDARY DIAGNOSES :
1 . Chronic obstructive pulmonary disease .
2 . Coronary artery disease .
PROCEDURES : Robotic - Assisted laparoscopic left renal cyst decortication and cystoscopy.
HISTORY OF PRESENT ILLNESS : Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts . He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma . Of note , there are no other enhancing solid masses seen on this MRI .
After discussion of multiple management strategies with the patient including :
1 . Left partial nephrectomy .
2 . Left radical nephrectomy .
3 . Left renal cyst decortication .
The patient is likely to undergo the latter procedure .
HOSPITAL COURSE :
The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy. Intraoperatively , approximately four enlarged renal cysts and six smaller renal cysts were initially removed . The contents were aspirated and careful dissection of the cyst wall was performed . Multiple specimens of the cyst wall were sent for pathology . Approximately one liter of cystic fluid was drained during the procedure . The renal bed was inspected for hemostasis , which appear to be adequate . There were no complications with the procedure . Single JP drain was left in place . Additionally , the patient underwent flexible cystoscopy , which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra . Furthermore , no gross lesions were encountered in the bladder . The patient left OR with transfer to the PACU and subsequently to the hospital floor . The patient's postoperative course was relatively uneventful . His diet and activity were gradually advanced without complication . On postoperative day #2 , he was passing flatus and has had bowel movements. His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge . His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly . At the time of discharge, he was afebrile . His vital signs indicated hemodynamic stability and he had no evidence of infection . The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative .
DISPOSITION :
To home .
DISCHARGE CONDITION :
Good .
MEDICATIONS :
Please see attached medication list .
INSTRUCTIONS :
The patient was instructed to contact Dr. XYZ ' s office for fever greater than 101.5 , intractable pain, nausea , vomiting , or any other concerns .
FOLLOWUP : The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment .
Keywords : discharge summary , decortication , cystoscopy , pain , nausea , vomiting , renal cyst decortication , renal cell carcinoma , robotic assisted , renal cyst , renal , robotic , laparoscopic , nephrectomy , cysts , cell , carcinoma , discharge , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"\n",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"Nephrology",
"Description",
":",
"P",
"\n",
"atient",
"with",
"left",
"renal",
"cell",
"carcinoma",
",",
"left",
"ren... | [
{
"char_end": 150,
"char_start": 125,
"text": "left renal cell carcinoma",
"token_end": 27,
"token_start": 23,
"type": "problem"
},
{
"char_end": 135,
"char_start": 125,
"text": "left renal",
"token_end": 25,
"token_start": 23,
"type": "bodyloc"
},
{
"char... | train/27_20210610044410_Isra |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary
Description: Speech therapy discharge summary. The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.
(Medical Transcription Sample Report)
The patient is a 78-year-old female, who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive-linguistic deficits. Outpatient skilled speech therapy was recommended for two times a week to improve her overall memory, executive function, attention, and visuospatial skills. The patient made excellent progress during the therapy and she accomplished all of her short-term therapy goals. She is able to name 15 items in a broad category with minimal queuing. The patient can sequence activities with greater than 90% accuracy with minimal queuing. She is able to follow a 3 step direction with greater than 80% accuracy, and she is able to complete visual scanning tasks with greater than 80% accuracy. The patient is currently able to listen to and/or read a narrative and be able to recall the main idea plus 3 supporting elements after a 3-minute delay.
LONG-TERM GOALS: Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community. This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home. During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill. She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment.
The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued. The patient and her husband both agreed with the patient's discharge.
Keywords:
discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speech,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Speech",
"Therapy",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Speech",
"therapy",
"discharge",
"summary",
".",
"The",
"patient",
"was",
"adm... | [
{
"char_end": 78,
"char_start": 64,
"text": "Speech Therapy",
"token_end": 14,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 126,
"char_start": 112,
"text": "Speech therapy",
"token_end": 22,
"token_start": 20,
"type": "treatment"
},
{
"char_end"... | train/2_20210604143805_Hayden |
Sample Type / Medical Specialty : General Medicine
Sample Name : Normal
ROS Template - 2 Description : Normal
review of systems template .
Negative weakness , negative fatigue , native malaise , negative chills , negative fever , negative night sweats , negative allergies . ( Medical Transcription Sample Report )
GENERAL : Negative weakness , negative fatigue , native malaise , negative chills , negative fever , negative night sweats , negative allergies .
INTEGUMENTARY : Negative rash , negative jaundice .
HEMATOPOIETIC : Negative bleeding , negative lymph node enlargement , negative bruisability .
NEUROLOGIC : Negative headaches , negative syncope , negative seizures , negative weakness , negative tremor . No history of strokes , no history of other neurologic conditions .
EYES : Negative visual changes , negative diplopia , negative scotomata , negative impaired vision . EARS : Negative tinnitus , negative vertigo , negative hearing impairment . NOSE AND THROAT : Negative postnasal drip , negative sore throat .
CARDIOVASCULAR : Negative chest pain , negative dyspnea on exertion , negative palpations , negative edema .
No history of heart attack , no history of arrhythmias , no history of hypertension .
RESPIRATORY : No history of shortness of breath , no history of asthma , no history of chronic obstructive pulmonary disease , no history of obstructive sleep apnea . GASTROINTESTINAL : Negative dysphagia , negative nausea , negative vomiting , negative hematemesis , negative abdominal pain .
GENITOURINARY : Negative frequency , negative urgency , negative dysuria , negative incontinence . No history of STDs .
MUSCULOSKELETAL : Negative myalgia , negative joint pain , negative stiffness , negative weakness , negative back pain .
PSYCHIATRIC : See psychiatric evaluation . ENDOCRINE : No history of diabetes mellitus , no history of thyroid problems , no history of endocrinologic abnormalities .
Keywords : general medicine , nose and throat , cardiovascular , integumentary , negative weakness , neurologic , throat , psychiatric , weakness , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"\n",
"ROS",
"Template",
"-",
"2",
"Description",
":",
"Normal",
"\n",
"review",
"of",
"systems",
"template",
".",
"\n",
"Negative",
"weakness",... | [
{
"char_end": 151,
"char_start": 143,
"text": "Negative",
"token_end": 29,
"token_start": 28,
"type": "negation"
},
{
"char_end": 160,
"char_start": 152,
"text": "weakness",
"token_end": 30,
"token_start": 29,
"type": "problem"
},
{
"char_end": 171,
"c... | train/2_20210610044403_Isra |
Sample Type/Medical Specialty : General Medicine
Sample Name : Normal Physical Exam Template - 5
Description : N
ormal Physical Exam Template. Well developed , well nourished , alert , in no acute distress . ( Medical Transcription Sample Report ) GENERAL : Well developed , well nourished , alert , in no acute distress . GCS 50 , nontoxic .
VITAL SIGNS :
Blood pressure * , pulse * , respirations * , temperature * degrees F . Pulse oximetry *% .
HEENT : Eyes : Lids and conjunctiva . No lesions . Pupils equal , round , reactive to light and accommodation . Irises symmetrical , undilated . Funduscopic exam reveals no hemorrhages or discopathy .
Ears , Nose , Mouth , and throat : External ears without lesions . Nares patent . Septum midline . Tympanic membranes without erythema , bulging or retraction . Canals without lesion . Hearing is grossly intact . Lips , teeth , gums , palate without lesion . Posterior oropharynx : No erythema . No tonsillar enlargement , crypt formation or abscess .
NECK : Supple and symmetric . No masses . Thyroid midline , non enlarged . No JVD . Neck is nontender . Full range of motion without pain .
RESPIRATORY : Good respiratory effort . Clear to auscultation . Clear to percussion . Chest : Symmetrical rise and fall . Symmetrical expansion . No egophony or tactile fremitus .
CARDIOVASCULAR : Regular rate and rhythm . No murmur , gallops , clicks , heaves or rub . Cardiac palpation within normal limits . Pulses equal at carotid . Femoral and pedal pulses : No peripheral edema .
GASTROINTESTINAL : No tenderness or mass . No hepatosplenomegaly . No hernia . Bowel sounds equal times four quadrants . Abdomen is nondistended . No rebound , guarding , rigidity or ecchymosis .
MUSCULOSKELETAL : Normal gait and station . No pathology to digits or nails . Extremities move times four . No tenderness or effusion . Range of motion adequate . Strength and tone equal bilaterally , stable .
BACK : Nontender on midline . Full range of motion with flexion , extension and sidebending .
SKIN : Inspection within normal limits . Well hydrated . No diaphoresis . No obvious wound . LYMPH : Cervical lymph nodes . No lymphadenopathy .
NEUROLOGICAL : Cranial nerves II - XII grossly intact .
DTRs symmetric 2 out of 4 bilateral upper and lower extremity , elbow , patella and ankle . Motor strength 4/4 bilateral upper and lower extremity . Straight leg raise is negative bilaterally .
PSYCHIATRIC : Judgment and insight adequate . Alert and oriented times three . Memory and mood within normal limits . No delusions , hallucinations . No suicidal or homicidal ideation .
Keywords : general medicine , respiratory , abdomen , normal physical exam , pulses , tenderness , strength , lymph , extremity , midline , range , motion , lesions , symmetrical , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Physical",
"Exam",
"Template",
"-",
"5",
"\n",
"Description",
":",
"N",
"\n",
"ormal",
"Physical",
"Exam",
"Template",
".",
"Well",
"developed"... | [
{
"char_end": 192,
"char_start": 190,
"text": "no",
"token_end": 38,
"token_start": 37,
"type": "negation"
},
{
"char_end": 207,
"char_start": 193,
"text": "acute distress",
"token_end": 40,
"token_start": 38,
"type": "problem"
},
{
"char_end": 307,
"c... | train/30_20210610044412_Isra |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 14
Description: The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis. Biopsies were done. The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.
PAST MEDICAL HISTORY: Extensive and well documented in prior charts.
PHYSICAL EXAMINATION: Abdomen was diffusely tender. Lungs clear. Blood pressure 129/69 on admission. At the time of admission, she had just a trace of bilateral lower edema.
LABORATORY STUDIES: White count 6.7, hemoglobin 13, hematocrit 39.3. Potassium of 3.2 on 08/15/2007.
HOSPITAL COURSE: Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema. This was done and did not really show what the cecum on the barium enema. There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon. She did have some enemas. She had persistent nausea, headache, neck pain throughout this hospitalization. Finally, she did improve enough to the point where she could be discharged home.
DISCHARGE DIAGNOSIS: Nausea and abdominal pain of uncertain etiology.
SECONDARY DIAGNOSIS: Migraine headache.
COMPLICATIONS: None.
DISCHARGE CONDITION: Guarded.
DISCHARGE PLAN: Follow up with me in the office in 5 to 7 days to resume all pre-admission medications. Diet and activity as tolerated.
Keywords:
discharge summary, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"14",
"\n",
"Description",
":",
"The",
"patient",
"is",
"a",
"60",
"-",
"year",
"-",
"old",
"female",
"patient",
"who",
... | [
{
"char_end": 217,
"char_start": 209,
"text": "diarrhea",
"token_end": 46,
"token_start": 45,
"type": "problem"
},
{
"char_end": 225,
"char_start": 219,
"text": "nausea",
"token_end": 48,
"token_start": 47,
"type": "problem"
},
{
"char_end": 243,
"char... | train/32_20210604143814_Isra |
Sample Type/Medical Specialty : General Medicine Sample
Name : Normal ROS Template - 3
Description : Normal
review of systems template . No history of headaches , migraines , vertigo , syncope , visual loss , tinnitus , sinusitis , sore in the mouth , hoarseness , swelling or goiter . ( Medical Transcription Sample Report )
HEENT : No history of headaches , migraines , vertigo , syncope , visual loss , tinnitus , sinusitis , sore in the mouth , hoarseness , swelling or goiter .
RESPIRATORY : No shortness of breath , wheezing , dyspnea , pulmonary disease , tuberculosis or past pneumonias .
CARDIOVASCULAR : No history of palpitations , irregular rhythm , chest pain , hypertension , hyperlipidemia , diaphoresis , congestive heart failure , heart catheterization , stress test or recent cardiac tests .
GASTROINTESTINAL : No history of rectal bleeding , appetite change , abdominal pain , hiatal hernia , ulcer , jaundice , change in bowel habits or liver problems , and no history of inflammatory bowel problems .
GENITOURINARY : No dysuria , hematuria , frequency , incontinence or colic .
NERVOUS SYSTEM : No gait problems , strokes , numbness or muscle weakness .
PSYCHIATRIC : No history of emotional lability , depression or sleep disturbances .
ONCOLOGIC : No history of any cancer , change in moles or rashes . No history of weight loss . The patient has a good energy level .
ALLERGIC/LYMPH : No history of systemic allergy , abnormal lymph nodes or swelling .
MUSCULOSKELETAL : No fractures , motor weakness , arthritis or other joint pains .
Keywords : general medicine , review of systems , tinnitus , sinusitis , sore , mouth , hoarseness , goiter , heart , appetite , bowel , weakness , loss , swelling , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"Sample",
"\n",
"Name",
":",
"Normal",
"ROS",
"Template",
"-",
"3",
"\n",
"Description",
":",
"Normal",
"\n",
"review",
"of",
"systems",
"template",
".",
"No",
"history",
"of",
"hea... | [
{
"char_end": 142,
"char_start": 140,
"text": "No",
"token_end": 28,
"token_start": 27,
"type": "negation"
},
{
"char_end": 163,
"char_start": 154,
"text": "headaches",
"token_end": 31,
"token_start": 30,
"type": "problem"
},
{
"char_end": 175,
"char_s... | train/32_20210610044412_Hayden |
Sample Type/Medical Specialty : General Medicine Sample
Name : Normal Physical Exam Template - 6
Description : Normal physical exam template.
Normal appearance for chronological age, does not appear chronically ill. (Medical Transcription Sample Report)
VITAL SIGNS : Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.
CONSTITUTIONAL : Normal appearance for chronological age, does not appear chronically ill.
HEENT : The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear.
NECK : Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes.
RESPIRATORY : Lungs are clear to auscultation bilaterally. The patient has a normal respiratory rate, no signs of consolidation and no egophony. There are no retractions or secondary muscle use. Good bilateral breath sounds are noted.
CARDIOVASCULAR : No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop.
ABDOMEN : Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative.
GENITOURINARY : No bladder tenderness, negative flank pain.
MUSCULOSKELETAL : Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.
NEUROLOGIC : Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal.
HEME/LYMPH : No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.
PSYCHIATRIC : Normal with no overt depression or suicidal ideations.
Keywords : general medicine, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"Sample",
"\n",
"Name",
":",
"Normal",
"Physical",
"Exam",
"Template",
"-",
"6",
"\n",
"Description",
":",
"Normal",
"physical",
"exam",
"template",
".",
"\n",
"Normal",
"appearance",
... | [
{
"char_end": 194,
"char_start": 191,
"text": "not",
"token_end": 35,
"token_start": 34,
"type": "negation"
},
{
"char_end": 217,
"char_start": 202,
"text": "chronically ill",
"token_end": 38,
"token_start": 36,
"type": "problem"
},
{
"char_end": 213,
... | train/34_20210610044412_Hayden |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 47
Description: The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain. The patient was well visiting in ABC, with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got here, she was in severe pain and had fever. They came straight to the emergency room. She was admitted. She had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. Multiple blood studies have been done including cultures, febrile agglutinins, etc. She has had run a higher blood glucose to the normal and she has been on sliding scale insulin. She was not known previously to be a diabetic. All x-rays have not been helpful as far as to determine the etiology of her discomfort. MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.
PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: She was not known to be a diabetic until this admission. She had been hypertensive. She has been on medications and has been controlled. She has not had hyperlipidemia. She has had no thyroid problems. There has been no asthma, bronchitis, TB, emphysema or pneumonia. No tuberculosis. She has had no breast tumors. She has had no chest pain or cardiac problems. She has had gallbladder surgery. She has not had any gastritis or ulcers. She has had no kidney disease. She has had a hysterectomy. She has had 9 pregnancies and 8 living children. She had A&P repair. She had a sacral abscess after a spinal. It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal. There have been fractures and no significant arthritis. She has been quite active at her ranch in Mexico. She raises goats and cattle. She drives a tractor and in short, has been very active.
PHYSICAL EXAMINATION: She is a short female, alert. She is shivering. She has ice in her axilla and behind her neck. She is febrile to 101 degrees F. She is alert. Her complaint is that of hip pain in the posterior sacroiliac joint area. She moves both her upper extremities well. She can move her right leg well. She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint. She cannot stand, sit or turn without severe pain. She has normal knee reflexes. No ankle reflexes. She has bounding tibial pulses. No sensory deficit. She says she knows when she has to void. She has a healed scar in the upper sacral region. There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.
PLAN: My plan is to do a triple-phase bone scan. I am suspecting an infection possibly in the left sacroiliac joint. It is probably some type of bacterium, the etiology of which is undetermined. She has had a normal white count despite her fever. There has been a history of brucellosis in the past, but her titers at this time are negative. Continue medication which included antibiotics and also the Motrin and Darvocet.
Keywords:
general medicine, inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"47",
"\n",
"Description",
":",
"The",
"patient",
"had",
"temperature",
"of",
"104",
"degrees",
"F.",
"It",
"has",
"been",... | [
{
"char_end": 124,
"char_start": 113,
"text": "temperature",
"token_end": 24,
"token_start": 23,
"type": "test"
},
{
"char_end": 141,
"char_start": 128,
"text": "104 degrees F",
"token_end": 28,
"token_start": 25,
"type": "labvalue"
},
{
"char_end": 219,
... | train/35_20210604143815_Isra |
Sample Type/Medical Specialty : General Medicine Sample
Name : Gen Med SOAP - 5
Description :
General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, (Medical Transcription Sample Report) S : The patient is here today with his mom for several complaints. Number one, he has been having issues with his right shoulder. Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. He has been having issues ever since. He is having difficulties raising his arm over his head. He does have some intermittent numbness in his fingers at night. He is not taking any anti - inflammatories or pain relievers. He is also complaining of a sore throat. He did have some exposure to Strep and he has a long history of strep throat. Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. He is also being seen for ADHD by Dr. B. Adderall and Zoloft. He takes these once a day. He does notice when he does not take his medication. He is doing well in school. He is socializing well. He is maintaining his weight and tolerating the medications. However, he is having issues with anger control. He realizes when he has anger outbursts that it is a problem. His mom is concerned. He actually was willing to go to counseling and was wondering if there was anything available for him at this time.
PAST MEDICAL/SURGICAL/SOCIAL HISTORY :
Reviewed and unchanged.
O : VSS. In general, patient is A & Ox3. NAD.
Heart : RRR.
Lungs : CTA.
HEENT : Unremarkable. He does have 2 + tonsils, no erythema or exudate noted except for some postnasal drip. Musculoskeletal : Limited in range of motion, active on the right. He stops at about 95 degrees. No muscle weakness. Neurovascularly intact. Negative biceps tenderness.
Psych : No suicidal, homicidal ideations. Answering questions appropriately. No hallucinations.
A/P :
1. Right shoulder bursitis. Check x-ray. Rule out fracture, and physical therapy if negative. Continue anti-inflammatories. Suggested joint injections but he denied.
2. Pharyngitis. At moms insistence, we will refer to ENT for possible tonsillectomy. Dr. A name was given.
3. Attention deficit disorder and anger control. Continue present management. Prescriptions x 3 months were given, also names for counseling for his anger issues. He is to RTC in 3 months or as needed.
Keywords : general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"Sample",
"\n",
"Name",
":",
"Gen",
"Med",
"SOAP",
"-",
"5",
"\n",
"Description",
":",
"\n",
"General",
"Medicine",
"SOAP",
"note",
".",
"Patient",
"with",
"shoulder",
"bursitis",
"... | [
{
"char_end": 155,
"char_start": 138,
"text": "shoulder bursitis",
"token_end": 30,
"token_start": 28,
"type": "problem"
},
{
"char_end": 146,
"char_start": 138,
"text": "shoulder",
"token_end": 29,
"token_start": 28,
"type": "bodyloc"
},
{
"char_end": 168... | train/36_20210610044412_Hayden |
Sample Type/Medical Specialty : General Medicine Sample
Name : Diabetes Mellitus - SOAP Note - 2
Description :
Patient today with ongoing issues with diabetic control. (Medical Transcription Sample Report)
SUBJECTIVE :
I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change. What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. The staff reports to me that her appetite is good and that she is eating as well as ever. I talked to Anna today. She feels a little fatigued. Otherwise, she is doing well.
PHYSICAL EXAMINATION : Vitals as in the chart. The patient is a pleasant and cooperative. She is in no apparent distress.
ASSESSMENT AND PLAN :
Diabetes, still with some problematic low blood glucoses, most notably in the morning. To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning. She will get 55 units in the morning. I am also decreasing once again her Humalog sliding scale insulin prior to meals. I will review the blood glucoses again next week.
Keywords : general medicine, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"Sample",
"\n",
"Name",
":",
"Diabetes",
"Mellitus",
"-",
"SOAP",
"Note",
"-",
"2",
"\n",
"Description",
":",
"\n",
"Patient",
"today",
"with",
"ongoing",
"issues",
"with",
"diabetic"... | [
{
"char_end": 81,
"char_start": 64,
"text": "Diabetes Mellitus",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 169,
"char_start": 133,
"text": "ongoing issues with diabetic control",
"token_end": 31,
"token_start": 26,
"type": "problem"
... | train/37_20210621151709_Hayden |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 15
Description: Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.
(Medical Transcription Sample Report)
FINAL DIAGNOSES:
1. Gastroenteritis.
2. Autism.
DIET ON DISCHARGE: Regular for age.
MEDICATIONS ON DISCHARGE: Adderall and clonidine for attention deficit hyperactivity disorder.
ACTIVITY ON DISCHARGE: As tolerated.
DISPOSITION ON DISCHARGE: Follow up with Dr. X in ABC Office in 1 to 2 weeks.
HISTORY OF PRESENT ILLNESS: This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. She developed vomiting 3 days prior to admission, but did not have diarrhea. She voided on the day of admission. When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight. She was admitted because of the persistent vomiting, but there was concern about the weight loss.
Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.
LABORATORY DATA: Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64. Chest x-ray and abdominal films were unremarkable. Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800. Urinalysis was negative for ketones. Specific gravity 1.023, and negative for protein. Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118. Thyroid peroxidase antibody studies are pending.
HOSPITAL COURSE: The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated. On the second hospital day, mother was comfortable taking her to home. Mother did not have a good explanation for the weight loss. In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94. Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.
She seem quite happy and in no distress at the time of discharge. We will follow up in the office and try to further evaluate her for the unexplained weight loss. She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss. The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.
Keywords:
discharge summary, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"15",
"\n",
"Description",
":",
"Gastroenteritis",
"and",
"autism",
".",
"She",
"developed",
"constipation",
"one",
"week",
"p... | [
{
"char_end": 115,
"char_start": 100,
"text": "Gastroenteritis",
"token_end": 20,
"token_start": 19,
"type": "problem"
},
{
"char_end": 126,
"char_start": 120,
"text": "autism",
"token_end": 22,
"token_start": 21,
"type": "problem"
},
{
"char_end": 154,
... | train/38_20210604143816_Isra |
Sample Type/Medical Specialty : Discharge Summary Sample
Name : Pancreatic Mass - Discharge Summary
Description :
The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ( Medical Transcription Sample Report )
HISTORY OF PRESENT ILLNESS : The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30 - pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin - slice CT scan was performed, which revealed a 4x3x2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. The patient, additionally, had a questionable pseudocyst in the tail of the pancreas. The patient underwent ERCP on 04/04/2007 with placement of a stent. This revealed a strictured pancreatic duct, as well as strictured bile duct. A 10-frenchx9 cm stent was placed with good drainage. The next morning, the patient felt quite a bit more comfortable. He additionally had a modest drop in his bilirubin and other liver tests. Of note, the patient has been having quite a bit of nausea during his admission. This responded to Zofran. It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself.
At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000. His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3. His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8. He was tolerating a regular diet. The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale. The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary. He will be further managed for his diabetes there. The patient will additionally undergo potential end of life meetings. I discussed the potentials of chemotherapy with patient. Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity. The patient will consider this and will discuss this further with Dr. X.
DISCHARGE MEDICATIONS :
1. Phenergan 25 mg q.6. p.r.n.
2. Duragesic patch 100 mcg q.3.d.
3. Benadryl 25-50 mg p.o. q.i.d. for pruritus.
4. Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.
5. The patient had initially been on enalapril here. His hypertension will be managed by Dr. X as well.
PLAN :
The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain. In the meantime, he will be kept on a regular diet and activity per Dr. X.
Keywords : discharge summary, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"Sample",
"\n",
"Name",
":",
"Pancreatic",
"Mass",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"\n",
"The",
"patient",
"has",
"had",
"abdominal",
"pain",
"associated",
"with... | [
{
"char_end": 80,
"char_start": 65,
"text": "Pancreatic Mass",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 75,
"char_start": 65,
"text": "Pancreatic",
"token_end": 13,
"token_start": 12,
"type": "bodyloc"
},
{
"char_end": 151,
... | train/38_20210610044413_Hayden |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 29
Description: Patient with intermittent episodes of severe nausea and abdominal pain.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair.
PAST MEDICAL HISTORY: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension.
MEDICATIONS: His only medications are Ziac and Remeron.
ALLERGIES: No allergies.
FAMILY HISTORY: Negative for cancer.
SOCIAL HISTORY: He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions.
PHYSICAL EXAMINATION:
GENERAL: Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.
HEENT: No scleral icterus.
NECK: No cervical, supraclavicular, or axillary adenopathy.
LUNGS: Clear.
HEART: Regular. No murmurs or gallops.
ABDOMEN: As noted, obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.
DIAGNOSTIC STUDIES: Normal sinus rhythm on EKG, prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5, hematocrit was 48, and platelet count was 307.
ASSESSMENT AND PLAN: Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.
Keywords:
general medicine, sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"29",
"\n",
"Description",
":",
"Patient",
"with",
"intermittent",
"episodes",
"of",
"severe",
"nausea",
"and",
"abdominal",
... | [
{
"char_end": 148,
"char_start": 110,
"text": "intermittent episodes of severe nausea",
"token_end": 27,
"token_start": 22,
"type": "problem"
},
{
"char_end": 167,
"char_start": 153,
"text": "abdominal pain",
"token_end": 30,
"token_start": 28,
"type": "problem"
... | train/41_20210604143816_Isra |
Sample Type/Medical Specialty :
Discharge Summary Sample
Name : Hysterectomy-Discharge Summary-1
Description :
Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids. (Medical Transcription Sample Report)
ADMISSION DIAGNOSES :
1. Menometrorrhagia.
2. Dysmenorrhea.
3. Small uterine fibroids.
DISCHARGE DIAGNOSES :
1. Menorrhagia.
2. Dysmenorrhea.
3. Small uterine fibroids.
OPERATION PERFORMED :
Total vaginal hysterectomy.
BRIEF HISTORY AND PHYSICAL :
The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries. She is having increasing menometrorrhagia and dysmenorrhea. Ultrasound shows a small uterine fibroid. She has failed oral contraceptives and surgical therapy is planned. PAST HISTORY : Significant for reflux.
SURGICAL HISTORY : Tubal ligation.
PHYSICAL EXAMINATION : A top normal sized uterus with normal adnexa.
LABORATORY VALUES : Her discharge hemoglobin is 12.4.
HOSPITAL COURSE :
She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia. Postoperatively, she has done well. Bowel and bladder function have returned normally. She is ambulating well, tolerating a regular diet. Routine postoperative instructions given and said follow up will be in four weeks in the office.
DISCHARGE MEDICATIONS : Preoperative meds plus Vicodin for pain.
DISCHARGE CONDITION : Good.
Keywords : discharge summary, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"\n",
"Discharge",
"Summary",
"Sample",
"\n",
"Name",
":",
"Hysterectomy",
"-",
"Discharge",
"Summary",
"-",
"1",
"\n",
"Description",
":",
"\n",
"Total",
"vaginal",
"hysterectomy",
".",
"Menometrorrhagia",
"... | [
{
"char_end": 78,
"char_start": 66,
"text": "Hysterectomy",
"token_end": 14,
"token_start": 13,
"type": "treatment"
},
{
"char_end": 141,
"char_start": 115,
"text": "Total vaginal hysterectomy",
"token_end": 26,
"token_start": 23,
"type": "treatment"
},
{
... | train/42_20210610044414_Hayden |
Sample Type / Medical Specialty: General Medicine
Sample Name: Airway Compromise & Foreign Body - ER Visit
Description: The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.
PAST MEDICAL HISTORY: Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Negative for illicit drugs, alcohol, and tobacco.
PHYSICAL EXAMINATION: Please see the hospital chart.
LABORATORY DATA: Please see the hospital chart.
HOSPITAL COURSE: The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. If not she would require tracheostomy. The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week.
Keywords:
general medicine, diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Airway",
"Compromise",
"&",
"Foreign",
"Body",
"-",
"ER",
"Visit",
"\n",
"Description",
":",
"The",
"patient",
"is",
"a",
"17",
"-",
"year",
"-",
"ol... | [
{
"char_end": 80,
"char_start": 63,
"text": "Airway Compromise",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 95,
"char_start": 83,
"text": "Foreign Body",
"token_end": 17,
"token_start": 15,
"type": "problem"
},
{
"char_end": 209... | train/44_20210604143817_Isra |
Sample Type/Medical Specialty : Discharge Summary Sample
Name : Hysterectomy - Discharge Summary - 2
Description : Total vaginal hysterectomy.
Microinvasive carcinoma of the cervix. (Medical Transcription Sample Report)
ADMISSION DIAGNOSIS : Microinvasive carcinoma of the cervix.
DISCHARGE DIAGNOSIS : Microinvasive carcinoma of the cervix.
PROCEDURE PERFORMED : Total vaginal hysterectomy.
HISTORY OF PRESENT ILLNESS : The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation. She had an abnormal Pap smear in the 80s, which she failed to followup on until this year. Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion. She has elected definitive therapy with a total vaginal hysterectomy. She is aware of the future need of Pap smears.
PAST MEDICAL HISTORY :
Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.
PHYSICAL EXAMINATION :
Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.
LABORATORY DATA AND DIAGNOSTIC STUDIES :
Chest x-ray was clear. Discharge hemoglobin 10.8.
HOSPITAL COURSE :
She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia. There was an incidental cystotomy at the time of the creation of the bladder flap. This was repaired intraoperatively without difficulty. Postoperative, she did very well. Bowel and bladder function returned quickly. She is ambulating well and tolerating a regular diet. Routine postoperative instructions given and understood. Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time.
DISCHARGE MEDICATIONS :
Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.
DISCHARGE CONDITION : Good. Final pathology report was free of residual disease.
Keywords : discharge summary, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"Sample",
"\n",
"Name",
":",
"Hysterectomy",
"-",
"Discharge",
"Summary",
"-",
"2",
"\n",
"Description",
":",
"Total",
"vaginal",
"hysterectomy",
".",
"\n",
"Microinvasive",
"carcinoma",... | [
{
"char_end": 77,
"char_start": 65,
"text": "Hysterectomy",
"token_end": 13,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 143,
"char_start": 117,
"text": "Total vaginal hysterectomy",
"token_end": 24,
"token_start": 21,
"type": "treatment"
},
{
... | train/44_20210610044415_Hayden |
Sample Type/Medical Specialty : Discharge Summary Sample
Name : Back & Leg Pain - Discharge Summary
Description :
Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome. (Medical Transcription Sample Report)
ADMISSION DIAGNOSIS : Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. SECONDARY DIAGNOSIS : Chronic pain syndrome.
PRINCIPAL PROCEDURE : L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.
BRIEF HISTORY OF HOSPITAL COURSE :
The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p. o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.
DISCHARGE MEDICATIONS :
Discharge medications included his usual preoperative pain medication as well as other medications.
FOLLOWUP : At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noted
Keywords : discharge summary, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"Sample",
"\n",
"Name",
":",
"Back",
"&",
"Leg",
"Pain",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"\n",
"Bilateral",
"l5",
"spondylolysis",
"with",
"pars",
"defects",
"... | [
{
"char_end": 80,
"char_start": 65,
"text": "Back & Leg Pain",
"token_end": 16,
"token_start": 12,
"type": "problem"
},
{
"char_end": 69,
"char_start": 65,
"text": "Back",
"token_end": 13,
"token_start": 12,
"type": "bodyloc"
},
{
"char_end": 75,
"char... | train/46_20210610044418_Hayden |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 48
Description: The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain.
(Medical Transcription Sample Report)
HISTORY: The patient presents today for medical management. The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. She has been off her supplements for four weeks with some improvement. She has loose bowel movements. She complains of no bladder control. She has pain in her hips. The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.
DIAGNOSES:
1. Type II diabetes mellitus.
2. Generalized fatigue and weakness.
3. Hypertension.
4. Peripheral neuropathy with atypical symptoms.
5. Hypothyroidism.
6. Depression.
7. Long-term use of high-risk medications.
8. Postmenopausal age-related symptoms.
9. Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.
CURRENT MEDICATIONS: Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.
PAST SURGICAL HISTORY: As listed on 04/22/04 along with allergies 04/22/04.
FAMILY HISTORY: Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy.
SOCIAL HISTORY: She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker.
REVIEW OF SYSTEMS:
GENERAL: Certainly at the present time on general exam no fever, sweats or chills and no significant weight change. She is 189 pounds currently and she was 188 pounds in January.
HEENT: HEENT, there is no marked decrease in visual or auditory function. ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.
RESPIRATORY: Chest, there is no history of palpitations, PND or orthopnea. The chest pains are nonspecific, tenderness to palpation has been reported. There is no wheezing or cough reported.
CARDIOVASCULAR: No PND or orthopnea. Thromboembolic disease history.
GASTROINTESTINAL: Intermittent symptoms of stomach pain, they are nonspecific. No nausea or vomiting noted. Diarrhea is episodic and more related to nerves.
GENITOURINARY: She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.
MUSCULOSKELETAL: Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.
NEUROLOGICAL: No marked paralysis, paresis or paresthesias.
SKIN: No rashes, itching or changes in the nails.
BREASTS: No report of any lumps or masses.
HEMATOLOGY AND IMMUNE: No bruising or bleeding-type symptoms.
PHYSICAL EXAMINATION:
WEIGHT: 189 pounds. BP: 140/80. PULSE: 76. RESPIRATIONS: 20. GENERAL APPEARANCE: Well developed, well nourished. No acute distress.
HEENT: Head is normocephalic. Ears, nose, and throat, normal conjunctivae. Pupils are reactive. Ear canals are patent. TMs are normal. Nose, nares patent. Septum midline. Oral mucosa is normal in appearance. No tonsillar lesions, exudate or asymmetry. Neck, adequate range of motion. No thyromegaly or adenopathy.
CHEST: Symmetric with clear lungs clear to auscultation and percussion.
HEART: Rate and rhythm is regular. S1 and S2 audible. No appreciable murmur or gallop.
ABDOMEN: Soft. No masses, guarding, rigidity, tenderness or flank pain.
GU: No examined.
EXTREMITIES: No cyanosis, clubbing or edema currently.
SKIN AND INTEGUMENTS: Intact. No lesions or rashes.
NEUROLOGIC: Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.
Additional information, the patient has been off metformin for few months and this is not part of her medication list.
IMPRESSION: As above.
PLAN:
1. Labs are CBC, CMP, A1c, microalbumin and UA. Stool for C&S, Gram stain, ova and parasites with intermittent diarrhea. She has planned CT of the abdomen and pelvis with and without.
2. She will continue with the current medications. She uses her diuretics at night.
3. Follow up will be in three months, sooner if indicated.
Keywords:
general medicine, medical management, fatigue, discomfort, loose bowel movements, diabetes mellitus, weakness, hypertension, peripheral neuropathy, intermittent diarrhea, symptoms,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"48",
"\n",
"Description",
":",
"The",
"patient",
"presents",
"to",
"the",
"office",
"today",
"with",
"complaints",
"of",
... | [
{
"char_end": 172,
"char_start": 157,
"text": "extreme fatigue",
"token_end": 32,
"token_start": 30,
"type": "problem"
},
{
"char_end": 210,
"char_start": 174,
"text": "discomfort in the chest and the back",
"token_end": 40,
"token_start": 33,
"type": "problem"
... | train/47_20210604143818_Isra |
Sample Type / Medical Specialty : General Medicine
Sample Name : Gen Med Consult - 31
Description :
Patient was confused , had garbled speech , significantly worse from her baseline , and had decreased level of consciousness . ( Medical Transcription Sample Report )
CHIEF COMPLAINT :
A 74 - year - old female patient admitted here with altered mental status .
HISTORY OF PRESENT ILLNESS : The patient started the last 3 - 4 days to do poorly . She was more confused , had garbled speech , significantly worse from her baseline . She has also had decreased level of consciousness since yesterday . She has had aphasia which is baseline but her aphasia has gotten significantly worse . She eventually became unresponsive and paramedics were called . Her blood sugar was found to be 40 because of poor p.o. intake . She was given some D50 but that did not improve her mental status , and she was brought to the emergency department . By the time she came to the emergency department , she started having some garbled speech . She was able to express her husband's name and also recognize some family members , but she continued to be more somnolent when she was in the emergency department . When seen on the floor , she is more awake , alert .
PAST MEDICAL HISTORY :
Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection . She has chronic incontinence and bladder atony , for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place . She has had right - sided CVA . She has had atrial fibrillation status post pacemaker . She is a type 2 diabetic with significant neuropathy . She has also had significant pain on the right side from her stroke . She has a history of hypothyroidism . Past surgical history is significant for cholecystectomy , colon cancer surgery in 1998 . She has had a pacemaker placement .
REVIEW OF SYSTEMS :
GENERAL : No recent fever , chills . No recent weight loss .
PULMONARY : No cough , chest congestion .
CARDIAC : No chest pain , shortness of breath .
GI : No abdominal pain , nausea , vomiting . No constipation . No bleeding per rectum or melena .
GENITOURINARY : She has had frequent urinary tract infection but does not have any symptoms with it .
ENDOCRINE : Unable to assess because of patient ' s bed - bound status .
MEDICATIONS :
Percocet 2 tablets 4 times a day , Neurontin 1 tablet b.i.d . 600 mg , Cipro recently started 500 b.i.d. , Humulin N 30 units twice a day . The patient had recently reduced that to 24 units . MiraLax 1 scoop nightly , Avandia 4 mg b.i.d . , Flexeril 1 tablet t.i.d. , Synthroid 125 mcg daily , Coumadin 5 mg . On the medical records , it shows she is also on ibuprofen , Lasix 40 mg b.i.d . , Lipitor 20 mg nightly , Reglan t.i.d. 5 mg , Nystatin powder . She is on oxygen chronically .
SOCIAL/FAMILY HISTORY :
She is married , lives with her husband , has 2 children that passed away and 4 surviving children . No history of tobacco use . No history of alcohol use . Family history is noncontributory .
PHYSICAL EXAMINATION :
GENERAL : She is awake , alert , appears to be comfortable .
VITAL SIGNS :
Blood pressure 111/43 , pulse 60 per minute , temperature 37.2 . Weight is 98 kg . Urine output is so far 1000 mL . Her intake has been fairly similar . Blood sugars are 99 fasting this morning .
HEENT : Moist mucous membranes . No pallor
NECK : Supple . She has a rash on her neck .
HEART : Regular rhythm , pacemaker could be palpated .
CHEST : Clear to auscultation .
ABDOMEN : Soft , obese , nontender .
EXTREMITIES : Bilateral lower extremities edema present . She is able to move the left side more efficiently than the right . The power is about 5 x 5 on the left and about 3-4 x 5 on the right . She has some mild aphasia . DIAGNOSTIC STUDIES : BUN 48 , creatinine 2.8 . LFTs normal . She is anemic with a hemoglobin of 9.6 , hematocrit 29 . INR 1.1 , pro time 14 . Urine done in the emergency department showed 20 white cells . It was initially cloudy but on the floor it has cleared up . Cultures from the one done today are pending . The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures . There is a question of her being allergic to Septra that was used for her last UTI .
IMPRESSION/PLAN :
1 . Cerebrovascular accident as evidenced by change in mental status and speech . She seems to have recovered at this point . We will continue Coumadin . The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years , the family has expressed the need for her to be on hospice and just continue comfort care at home .
2 . Recurrent urinary tract infection . Will await culture at this time , continue Cipro .
3 . Diabetes with episode of hypoglycemia . Monitor blood sugar closely , decrease the dose of Humulin N to 15 units twice a day since intake is poor . At this point , there is no clear evidence of any benefit from Avandia but will continue that for now .
4 . Neuropathy , continue Neurontin 600 mg b.i.d . , for pain continue the Percocet that she has been on .
5 . Hypothyroidism , continue Synthroid .
6 . Hyperlipidemia , continue Lipitor .
7 . The patient is not to be resuscitated . Further management based on the hospital course .
Keywords : general medicine , cerebrovascular accident , recurrent urinary tract infection , diabetes , hypoglycemia , neuropathy , hypothyroidism , hyperlipidemia , worse from her baseline , decreased level of consciousness , level of consciousness , urinary tract infection , decreased level , blood sugar , garbled speech , mental status , urinary tract , emergency department , decreased , confused , coumadin , blood , emergency , cultures , intake , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"31",
"\n",
"Description",
":",
"\n",
"Patient",
"was",
"confused",
",",
"had",
"garbled",
"speech",
",",
"significantly",
... | [
{
"char_end": 123,
"char_start": 115,
"text": "confused",
"token_end": 24,
"token_start": 23,
"type": "problem"
},
{
"char_end": 144,
"char_start": 130,
"text": "garbled speech",
"token_end": 28,
"token_start": 26,
"type": "problem"
},
{
"char_end": 166,
... | train/4_20210610044403_Isra |
Sample Type / Medical Specialty: General Medicine
Sample Name: Abdominal Pain - Consult
Description: The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.
PAST MEDICAL HISTORY: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.
PAST SURGICAL HISTORY: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.
ALLERGIES: SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.
SOCIAL HISTORY: She does not drink or smoke.
REVIEW OF SYSTEMS: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.
VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.
HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.
NECK: Supple.
CHEST: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.
PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.
EXTREMITIES: Grossly and neurovascularly intact.
LABORATORY VALUES: White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.
DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm.
IMPRESSION AND PLAN: A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.
Keywords:
general medicine, abdominal pain, lower quadrant, abdominal, sigmoid, diverticulitis, tenderness,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Abdominal",
"Pain",
"-",
"Consult",
"\n",
"Description",
":",
"The",
"patient",
"presented",
"to",
"the",
"emergency",
"room",
"last",
"evening",
"with",
... | [
{
"char_end": 77,
"char_start": 63,
"text": "Abdominal Pain",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 72,
"char_start": 63,
"text": "Abdominal",
"token_end": 13,
"token_start": 12,
"type": "bodyloc"
},
{
"char_end": 157,
... | train/50_20210604143818_Isra |
Sample Type/Medical
Specialty: Discharge Summary Sample
Name: Leiomyosarcoma
Description: Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia. ( Medical Transcription Sample Report )
ADMITTING DIAGNOSES:
1. Leiomyosarcoma.
2. History of pulmonary embolism.
3. History of subdural hematoma.
4. Pancytopenia.
5. History of pneumonia.
PROCEDURES DURING HOSPITALIZATION:
1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.
2. CTA, chest PE study showing no evidence for pulmonary embolism.
3. Head CT showing no evidence of acute intracranial abnormalities.
4. Sinus CT, normal mini-CT of the paranasal sinuses.
HISTORY OF PRESENT ILLNESS:
Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007. The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon. MRI showed inflammation and was thought to be secondary to rheumatoid arthritis. The mass increased in size. She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive. She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy. She began treatment with CIVI-CAD in December 2007. Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation. She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.
HOSPITAL COURSE:
1. Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.
2. History of pulmonary embolism. Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain. She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day. She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.
3. History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own. Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities. The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.
4. Pancytopenia. On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400. The patient's counts were followed throughout admission. She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet. At discharge her ANC is back up to 1100 and she is taken off neutropenic diet. Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.
5. History of pneumonia. During admission, the patient did not exhibit any signs or symptoms of pneumonia.
DISPOSITION: Home in stable condition.
DIET: Regular and less neutropenic.
ACTIVITY: Resume same activity.
FOLLOWUP:
The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m. The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.
Keywords: discharge summary, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary, | [
"Sample",
"Type",
"/",
"Medical",
"\n",
"Specialty",
":",
"Discharge",
"Summary",
"Sample",
"\n",
"Name",
":",
"Leiomyosarcoma",
"\n",
"Description",
":",
"Discharge",
"summary",
"of",
"patient",
"with",
"leiomyosarcoma",
"and",
"history",
"of",
"pulmonary",
"em... | [
{
"char_end": 78,
"char_start": 64,
"text": "Leiomyosarcoma",
"token_end": 14,
"token_start": 13,
"type": "problem"
},
{
"char_end": 141,
"char_start": 127,
"text": "leiomyosarcoma",
"token_end": 23,
"token_start": 22,
"type": "problem"
},
{
"char_end": 17... | train/50_20210610044419_Hayden |
Sample Type / Medical Specialty: General Medicine
Sample Name: Breast Calcifications - Preop Consult
Description: Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.
(Medical Transcription Sample Report)
REASON FOR HOSPITALIZATION: Suspicious calcifications upper outer quadrant, left breast.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position. Additional imaging studies confirmed the suspicious nature of these calcifications. The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08. The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis. No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.
Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast. She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy. I was called to see the patient in the emergency consultation in the breast center. At the same time, Dr. Y was consulted in Interventional Radiology. Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material. This resulted in immediate occlusion of the false aneurysm. The patient was seen in my office for followup appointment on 06/24/08. At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy. There was, however, no evidence of reforming of the false aneurysm. There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.
I discussed the issues with the patient and her husband. The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings. For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization. Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months. The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.
The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04. This revealed benign histologic findings. The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40. Other than her age, the patient has no other risk factors for development of breast cancer. She is not receiving any hormone replacement therapy. She has had five children with the first pregnancy occurring at the age of 24. Other than her daughter, there are no other family members with breast cancer. There are no family members with a history of ovarian cancer.
PAST MEDICAL HISTORY: Other hospitalizations have occurred for issues with asthma and pneumonia.
PAST SURGICAL HISTORY: Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.
CURRENT MEDICATIONS:
1. Plavix.
2. Arava.
3. Nexium.
4. Fosamax.
5. Advair.
6. Singulair.
7. Spiriva.
8. Lexapro.
DRUG ALLERGIES: ASPIRIN, PENICILLIN, IODINE AND CODEINE.
FAMILY HISTORY: Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.
SOCIAL HISTORY: The patient does not smoke. She does have an occasional alcoholic beverage.
REVIEW OF SYSTEMS: The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly aged female who is alert and in no distress.
HEENT: Head, normocephalic. Eyes, PERRL. Sclerae are clear. Mouth, no oral lesions.
NECK: Supple without adenopathy.
HEART: Regular sinus rhythm.
CHEST: Fair air entry bilaterally. No wheezes are noted on examination.
BREASTS: Normal topography bilaterally. There are no palpable abnormalities in either breast mound. Nipple areolar complexes are normal. Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses. The previous tissue changes from the stereotactic core needle biopsy have resolved. Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.
ABDOMEN: Obese. No masses. Normal bowel sounds are present.
BACK: No CVA tenderness.
EXTREMITIES: No clubbing, cyanosis or edema.
ASSESSMENT:
1. Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.
2. Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.
3. History of chronic obstructive lung disease and asthma, controlled with medications.
4. History of gastroesophageal reflux disease, controlled with medications.
5. History of transient ischemic attack managed with medications.
6. History of osteopenia and osteoporosis, controlled with medications.
7. History of anxiety controlled with medications.
PLAN: Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography. This will be performed on an outpatient basis.
Keywords:
general medicine, breast mound, stereotactic core needle biopsy, gastroesophageal reflux, needle biopsy, calcifications, biopsy, breast, stereotactic,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Breast",
"Calcifications",
"-",
"Preop",
"Consult",
"\n",
"Description",
":",
"Suspicious",
"calcifications",
"upper",
"outer",
"quadrant",
",",
"left",
"bre... | [
{
"char_end": 84,
"char_start": 63,
"text": "Breast Calcifications",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 69,
"char_start": 63,
"text": "Breast",
"token_end": 13,
"token_start": 12,
"type": "bodyloc"
},
{
"char_end": 160,
... | train/58_20210604143820_Isra |
Sample Type / Medical Specialty: General Medicine
Sample Name: Congestion & Cough - 5-month-Old
Description: A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Congestion and cough.
HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.
ALLERGIES: She has no known drug allergies.
MEDICATIONS: None except the Amoxil and Aldex started on Monday.
PAST MEDICAL HISTORY: Negative.
SOCIAL HISTORY: She lives with mom, sister, and her grandparent.
BIRTH HISTORY: She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.
IMMUNIZATIONS: Also up-to-date.
PAST SURGICAL HISTORY: Negative.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
VITAL SIGNS: Her respiratory rate was approximately 60 to 65.
GENERAL: She was very congested and she looked miserable. She had no retractions at this time.
HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.
NECK: Supple. Full range of motion.
CARDIOVASCULAR EXAM: She was tachycardic without murmur.
LUNGS: Revealed diffuse expiratory wheezing.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: Showed no clubbing, cyanosis or edema.
LABORATORY DATA: Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.
IMPRESSION AND PLAN: RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.
Keywords:
general medicine, rsv, bronchiolitis, otitis media, runny nose, difficulty breathing, nose, congestion, infant, congested, cough,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Congestion",
"&",
"Cough",
"-",
"5",
"-",
"month",
"-",
"Old",
"\n",
"Description",
":",
"A",
"5",
"-",
"month",
"-",
"old",
"infant",
"with",
"col... | [
{
"char_end": 73,
"char_start": 63,
"text": "Congestion",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 81,
"char_start": 76,
"text": "Cough",
"token_end": 15,
"token_start": 14,
"type": "problem"
},
{
"char_end": 139,
"char_st... | train/5_20210604143806_Hayden |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 16
Description: Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS: Upper respiratory illness with apnea, possible pertussis.
DISCHARGE DIAGNOSIS: Upper respiratory illness with apnea, possible pertussis.
COMPLICATIONS: None.
OPERATIONS: None
BRIEF HISTORY AND PHYSICAL: This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, questionable fever, but only 99.7. Their usual doctor prescribed amoxicillin over the phone. The coughing persisted and worsened. She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells. They did witness some apnea. They gave some Rocephin, did some labs, and the patient was transferred to hospital.
PHYSICAL EXAMINATION: On admission, GENERAL: Well-developed, well-nourished baby in no apparent distress. HEENT: There was some nasal discharge. Remainder of the HEENT was normal. LUNG: Had few rhonchi. No retractions. No significant coughing or apnea during the admission physical. ABDOMEN: Benign. EXTREMITIES: Were without any cyanosis.
SIGNIFICANT LABS AND X-RAYS: She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP. An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate. Well at hospital, she had a rapid influenza swab done, which was negative. She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative. She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart. I do know that the pertussis culture proved to be negative.
CONSULTATION: Public Health Department was notified of a case of suspected pertussis.
HOSPITAL COURSE: The baby was afebrile. Required no oxygen in the hospital. Actually fed reasonably well. Did have one episode of coughing with slight emesis. Appeared basically quite well between episodes. Had no apnea witnessed and after overnight observation, the parents were anxious to go home. The patient was started on Zithromax in the hospital.
CONDITION AND TREATMENT: The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.
INSTRUCTIONS TO PATIENT: Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.
Keywords:
discharge summary, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"16",
"\n",
"Description",
":",
"Upper",
"respiratory",
"illness",
"with",
"apnea",
",",
"possible",
"pertussis",
".",
"a",
... | [
{
"char_end": 125,
"char_start": 100,
"text": "Upper respiratory illness",
"token_end": 22,
"token_start": 19,
"type": "problem"
},
{
"char_end": 117,
"char_start": 100,
"text": "Upper respiratory",
"token_end": 21,
"token_start": 19,
"type": "bodyloc"
},
{
... | train/60_20210604143820_Isra |
Sample Type / Medical Specialty: General Medicine
Sample Name: Nausea - ER Visit
Description: Nausea and feeling faint. She complains of some nausea. She feels weak. The patient is advised to put salt on her food for the next week.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Nausea and feeling faint.
HPI: The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today, she complains of some nausea. She feels weak. No other specific complaints.
REVIEW OF SYSTEMS: The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.
CURRENT MEDICATIONS: Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.
ALLERGIES: MORPHINE CAUSES VOMITING.
PAST MEDICAL HISTORY: COPD and hypertension.
HABITS: Tobacco use, averages two cigarettes per day. Alcohol use, denies.
LAST TETANUS IMMUNIZATION: Not sure.
LAST MENSTRUAL PERIOD: Status post hysterectomy.
SOCIAL HISTORY: The patient is married and retired.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2, pulse is 105, respirations 20, and BP 137/80. GENERAL: A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated. SKIN: Warm, dry, and good color. EYES: EOMI. PERRL. MOUTH: Clear. Mucous membranes moist. NECK: Supple. No JVD. LUNGS: Reveal faint expiratory wheeze heard in the posterior lung fields. HEART: Slightly tachycardic without murmur. ABDOMEN: Soft, positive bowel sounds, and nontender. No rebound or guarding is appreciated. BACK: No CVA tenderness. EXTREMITIES: Moves all four extremities. No pretibial edema. NEURO: Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.
LABORATORY STUDIES: WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils. Hemoglobin 10.7 and hematocrit 31.2 both are decreased. Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2. Amylase and lipase both normal. Clean catch urinalysis is unremarkable. Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7. It seems to indicate that the patient had previous problems with anemia.
RADIOLOGY STUDIES: Chest x-ray indicates chronic changes, reviewed by me, official report is pending.
ED STUDIES: O2 sat on room air is 92%, which is satisfactory for this patient with COPD. Monitor indicates sinus tachycardia at rate 103. No ectopy.
ED COURSE: The patient was assessed for orthostatic vital sign changes and none were detected by the nurse. The patient was given albuterol unit dose small volume nebulizer treatment. Repeat lung exam reveals resolution of expiratory wheezing. The patient later had normal saline lock started by the nurse. She was given IV fluids of normal saline 1L wide open over approximately one hour. She was able to void urine indicating that she is well hydrated. Rectal examination was performed with female nurse in attendance. Good sphincter tone. No masses. The rectal secretions were heme negative. The patient was reassessed. She feels slightly better. Monitor now shows normal sinus rhythm, rate 81, no ectopy. Blood pressure is 136/66. The patient is stable and will be discharged.
MEDICAL DECISION MAKING: This patient presents with the above history. Laboratory evaluation today indicates the following problems, anemia and hyponatremia. This could contribute the patient's feelings of tiredness and not feeling well. There is no evidence of rectal bleeding at this time. The patient was advised that she needs to follow up with Dr. X to further investigate these problems. The patient is hemodynamically stable and will be discharged.
ASSESSMENT:
1. Acute tiredness.
2. Anemia of unknown etiology.
3. Acute hyponatremia.
PLAN: The patient is advised to put salt on her food for the next week. Should be given discharge instruction sheet for anemia. Recommend follow up with personal physician, Dr. X in two to three days for recheck. Return to ED sooner if condition changes or worsen anyway. Discharged in stable condition.
Keywords:
general medicine, fever, chills, sweats, ear pain, uri symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness, paresthesias, feeling faint, saline lock, edema, hemoglobin, nausea, wellbutrin,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Nausea",
"-",
"ER",
"Visit",
"\n",
"Description",
":",
"Nausea",
"and",
"feeling",
"faint",
".",
"She",
"complains",
"of",
"some",
"nausea",
".",
"She"... | [
{
"char_end": 69,
"char_start": 63,
"text": "Nausea",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 100,
"char_start": 94,
"text": "Nausea",
"token_end": 20,
"token_start": 19,
"type": "problem"
},
{
"char_end": 118,
"char_star... | train/62_20210604143820_Booma |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Multiple Trauma
Description: Aftercare of multiple trauma from an motor vehicle accident.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSIS: Aftercare of multiple trauma from an motor vehicle accident.
DISCHARGE DIAGNOSES:
1. Aftercare following surgery for injury and trauma.
2. Decubitus ulcer, lower back.
3. Alcohol induced persisting dementia.
4. Anemia.
5. Hypokalemia.
6. Aftercare healing traumatic fracture of the lower arm.
7. Alcohol abuse, not otherwise specified.
8. Aftercare healing traumatic lower leg fracture.
9. Open wound of the scalp.
10. Cervical disk displacement with myelopathy.
11. Episodic mood disorder.
12. Anxiety disorder.
13. Nervousness.
14. Psychosis.
15. Generalized pain.
16. Insomnia.
17. Pain in joint pelvic region/thigh.
18. Motor vehicle traffic accident, not otherwise specified.
PRINCIPAL PROCEDURES: None.
HISTORY OF PRESENT ILLNESS: As per Dr. X without any changes or corrections.
HOSPITAL COURSE: This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident. He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury. When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm. He had a brace placed in the left leg for his left tibial plateau fracture. He was confused initially and initially started on rehab. He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. He did well from orthopedic standpoint. He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. He made slow progress from therapy. His confusion gradually cleared. He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this. He did require some Ativan for agitation. He was on chronic pain medications as an outpatient. His medications were adjusted here and he did well with this as well. The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. We did have orthopedic followup. He was taken out of his right leg brace the week of 06/16/2008. He did well with therapy. Overall, he was doing much and much better. He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.
At the time of discharge, the patient's ambulatory status was much better. He was using a wheeled walker. He was able to bear weight on his left leg. His pain level had been well controlled and his moods had improved dramatically. He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. His anemia had resolved almost completely and he was doing quite well.
MEDICATIONS: On discharge included:
1. Calcium with vitamin D 1 tablet twice a day.
2. Ferrous sulfate 325 mg t.i.d.
3. Multivitamin 1 daily.
4. He was on nicotine patch 21 mg per 24 hour.
5. He was on Seroquel 25 mg at bedtime.
6. He was on Xenaderm for his sacral pressure ulcer.
7. He was on Vicodin p.r.n. for pain.
8. Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.
The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.
Keywords:
discharge summary, injury, trauma, multiple trauma, motor vehicle accident, decubitus ulcer, vehicle accident, discharge, aftercare, healing,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"Multiple",
"Trauma",
"\n",
"Description",
":",
"Aftercare",
"of",
"multiple",
"trauma",
"from",
"an",
"motor",
"vehicle",
"ac... | [
{
"char_end": 99,
"char_start": 84,
"text": "Multiple Trauma",
"token_end": 17,
"token_start": 15,
"type": "problem"
},
{
"char_end": 141,
"char_start": 126,
"text": "multiple trauma",
"token_end": 24,
"token_start": 22,
"type": "problem"
},
{
"char_end": ... | train/63_20210112211702 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Female Exam Template
Description: Sample/template for a normal female multisystem exam
(Medical Transcription Sample Report)
MULTISYSTEM EXAM
CONSTITUTIONAL: The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.
EYES: The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.
EARS, NOSE AND THROAT: The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.
NECK: The neck was supple. The thyroid gland was not enlarged by palpation.
RESPIRATORY: The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.
CARDIOVASCULAR: Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.
BREASTS: Breast inspection showed them to be symmetrical with no nipple discharge. Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.
GASTROINTESTINAL: The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.
GU: The external genitalia appeared to be normal. The pelvic exam revealed no adnexal masses. The uterus appeared to be normal in size and there was no cervical motion tenderness.
LYMPHATIC: There was no appreciated node that I could feel in the groin or neck area.
MUSCULOSKELETAL: The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.
SKIN: Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.
NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.
PSYCHIATRIC: The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.
Keywords:
general medicine, eyes, constitutional, within normal limits, tongue, multisystem, heart, ears, nose, respiratory, extremities, breasts, oropharynx, neck,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Female",
"Exam",
"Template",
"\n",
"Description",
":",
"Sample",
"/",
"template",
"for",
"a",
"normal",
"female",
"multisystem",
"exam",
"\n",
... | [
{
"char_end": 132,
"char_start": 126,
"text": "normal",
"token_end": 25,
"token_start": 24,
"type": "labvalue"
},
{
"char_end": 156,
"char_start": 133,
"text": "female multisystem exam",
"token_end": 28,
"token_start": 25,
"type": "test"
},
{
"char_end": 2... | train/65_20210604143822_Booma |
Sample Type / Medical Specialty: General Medicine
Sample Name: Antibiotic Therapy Consult
Description: Questionable need for antibiotic therapy for possible lower extremity cellulitis.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Questionable need for antibiotic therapy for possible lower extremity cellulitis.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospital. Her lower extremity edema is being managed there. She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her. As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management. She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas. Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.
I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.
PAST MEDICAL HISTORY: Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities. She has had a hysterectomy and a cholecystectomy in the remote past.
SOCIAL HISTORY: The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.
FAMILY HISTORY: Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.
ALLERGIES: ADHESIVE TAPE ALLERGIES.
REVIEW OF SYSTEMS: At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left. She denies any nausea, vomiting or diarrhea. She denies any pain, tenderness, increased warmth or drainage from the lower extremities. Denies chest pain, cough or phlegm production. All other systems reviewed were negative.
PHYSICAL EXAMINATION:
General: A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.
Vital signs: Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.
HEENT: Pupils are equal, round, and reactive to light. Extraocular movements intact. Head is normocephalic and external ear exam is normal.
Neck: Supple. There is no palpable lymphadenopathy.
Cardiovascular system: Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop. Heart sounds are little distant secondary to thick chest wall.
Lungs: Clear to auscultation and percussion bilaterally.
Abdomen: Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus. There is no evidence of cutaneous candidiasis in the inguinal folds. There is no palpable lymphadenopathy in the inguinal and femoral areas.
Extremities: Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis. There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area. It has minimal serosanguineous drainage and there is no surrounding erythema. Therefore, in my opinion, there is no current evidence of cellulitis or wound infection. There is no cyanosis or clubbing. There is no peripheral stigmata of endocarditis.
Central nervous system: The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.
LABORATORY DATA: White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils. The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5. Liver function tests are also within normal limits.
The nasal screen for MRSA is negative. Urine culture is negative so far from admission. Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.
IMPRESSION AND PLAN: A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema. Admitted for inpatient management of bilateral lower extremity lymphedema. I have been consulted to rule out possibility of active cellulitis and wound infection.
At present, I do not find evidence of active cellulitis that needs antibiotic therapy. In my opinion, lymphedema wraps could be initiated. We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week. If she develops any cellulitis, then appropriate antibiotic therapy will be initiated.
Her stage II ulcer on the right leg does not look infected. I would recommend continuation of wound care along with lymphedema wraps.
Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization. Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.
I appreciate the opportunity of participating in this patient's care. If you have any questions, please feel free to call me at any time. I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.
Keywords:
general medicine, bilateral lower extremity, lower extremity cellulitis, lower extremity lymphedema, active cellulitis, morbid obesity, lymphedema wraps, antibiotic therapy, lower extremity, cellulitis, lymphedema, antibiotic, therapy,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Antibiotic",
"Therapy",
"Consult",
"\n",
"Description",
":",
"Questionable",
"need",
"for",
"antibiotic",
"therapy",
"for",
"possible",
"lower",
"extremity",
... | [
{
"char_end": 143,
"char_start": 125,
"text": "antibiotic therapy",
"token_end": 23,
"token_start": 21,
"type": "drug"
},
{
"char_end": 156,
"char_start": 148,
"text": "possible",
"token_end": 25,
"token_start": 24,
"type": "uncertain"
},
{
"char_end": 183... | train/66_20210112211703 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Discharge Summary - 4
Description: Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.
(Medical Transcription Sample Report)
DATE OF ADMISSION: MM/DD/YYYY.
DATE OF DISCHARGE: MM/DD/YYYY.
ADMITTING DIAGNOSIS: Peritoneal carcinomatosis from appendiceal primary.
DISCHARGE DIAGNOSIS: Peritoneal carcinomatosis from appendiceal primary.
SECONDARY DIAGNOSIS: Diarrhea.
ATTENDING PHYSICIAN: AB CD, M.D.
SERVICE: General surgery C, Surgery Oncology.
CONSULTING SERVICES: Urology.
PROCEDURES DURING THIS HOSPITALIZATION: On MM/DD/YYYY,
1. Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.
2. Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.
HOSPITAL COURSE: The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY. He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement. The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement. Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C. The procedure was without complications. The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation. He was then transferred to the floor where he has done exceptionally well.
On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet. We advanced him as tolerated to a regular health select diet by postoperative day #4. His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used. He was then switched over to p.o. pain medicines and has required very little for adequate pain control. By postoperative date #2, the patient had been out of bed and ambulating in the hallways. The patient's only problem was with some mild diarrhea on postoperative days #3 and 4. This was thought to be a result of his right hemicolectomy. A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea. His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.
On the day of discharge, the patient was resting comfortably in the bed without complaints. He had been afebrile throughout his hospitalization and his vital signs were stable. Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout. His midline incision is clean, dry, and intact and staples are in place. He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.
CONDITION AT DISCHARGE: The patient was discharged in good and stable condition.
DISCHARGE MEDICATIONS:
1. Multivitamins daily.
2. Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.
3. Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.
4. Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.
5. Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.
DISCHARGE INSTRUCTIONS: The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.
FOLLOW-UP APPOINTMENT: The patient will be seen by Dr. XYZ in clinic in one week's time.
Keywords:
general medicine, carcinomatosis from appendiceal primary, tablet by mouth, stent placement, postoperative day, ureteral stents, peritoneal carcinomatosis, appendiceal primary, discharge, admitted, insertion, hemicolectomy, splenectomy, peritoneal, appendiceal, postoperatively, carcinomatosis, oncology,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"4",
"\n",
"Description",
":",
"Patient",
"admitted",
"after",
"an",
"extensive",
"workup",
"for",
"peritoneal",
"carcinomatosis"... | [
{
"char_end": 140,
"char_start": 121,
"text": "an extensive workup",
"token_end": 25,
"token_start": 22,
"type": "test"
},
{
"char_end": 170,
"char_start": 145,
"text": "peritoneal carcinomatosis",
"token_end": 28,
"token_start": 26,
"type": "problem"
},
{
... | train/66_20210604143822_Booma |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 45
Description: For evaluation of left-sided chest pain, 5 days post abdominal surgery.
(Medical Transcription Sample Report)
REASON FOR CONSULT: For evaluation of left-sided chest pain, 5 days post abdominal surgery.
PAST MEDICAL HISTORY: None.
HISTORY OF PRESENT COMPLAINT: This 87-year-old patient has been admitted in this hospital on 12/03/08. The patient underwent laparoscopic appendicectomy by Dr. X. The patient had postoperative paralytic ileus, which has resolved. The patient had developed left-sided chest pain yesterday. In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.
REVIEW OF SYSTEMS:
CONSTITUTIONAL SYMPTOMS: No recent fever.
ENT: Unremarkable.
RESPIRATORY: He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.
CARDIOVASCULAR: No known heart problems.
GASTROINTESTINAL: The patient denies nausea or vomiting. He is status post laparoscopic appendicectomy, and he is tolerating oral diet.
GENITOURINARY: No dysuria, no hematuria.
ENDOCRINE: Negative for diabetes or thyroid problems.
NEUROLOGIC: No history of CVA or TIA.
Rest of review of systems unremarkable.
SOCIAL HISTORY: The patient is a nonsmoker. He denies use of alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
GENERAL: An 87-year-old gentleman, not toxic looking.
HEAD AND NECK: Oral mucosa is moist.
CHEST: Clear to auscultation. No wheezing. No crepitations. There is reproducible tenderness over the left posterior-lateral axis.
CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.
ABDOMEN: Slightly distended. Bowel sounds are positive.
EXTREMITIES: He has 2+ to 3+ pedal swelling.
NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.
LABORATORY DATA: White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000. Glucose is 123, total protein is 6, and albumin is 2.9.
ASSESSMENT AND PLAN:
1. Ruptured appendicitis. The patient is 6 days post surgery. He is tolerating oral fluids and moving bowels.
2. Left-sided chest pain, need to rule out PE by distance of pretty low probability. The patient, however, has low-oxygen saturation. We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.
3. Fluid retention, manage as per surgeon.
4. Paralytic ileus, resolving.
5. Leukocytosis, we will monitor.
Keywords:
general medicine, ruptured appendicitis, chest pain, fluid retention, paralytic ileus, leukocytosis, abdominal surgery, laparoscopic appendicectomy, abdominal, surgery, chest,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"45",
"\n",
"Description",
":",
"For",
"evaluation",
"of",
"left",
"-",
"sided",
"chest",
"pain",
",",
"5",
"days",
"pos... | [
{
"char_end": 111,
"char_start": 101,
"text": "evaluation",
"token_end": 22,
"token_start": 21,
"type": "test"
},
{
"char_end": 136,
"char_start": 115,
"text": "left-sided chest pain",
"token_end": 28,
"token_start": 23,
"type": "problem"
},
{
"char_end": ... | train/69_20210112211703 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template
Description: Sample/template for a normal male multisystem exam.
(Medical Transcription Sample Report)
MULTISYSTEM EXAM
CONSTITUTIONAL: The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.
EYES: The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.
EARS, NOSE AND THROAT: The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.
NECK: The neck was supple. The thyroid gland was not enlarged by palpation.
RESPIRATORY: The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.
CARDIOVASCULAR: Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.
GASTROINTESTINAL: The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.
GU: The scrotal elements were normal. The testes were without discrete mass. The penis showed no lesion, no discharge.
LYMPHATIC: There was no appreciated node that I could feel in the groin or neck area.
MUSCULOSKELETAL: The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.
SKIN: Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.
NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.
PSYCHIATRIC: The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.
Keywords:
general medicine, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Male",
"Exam",
"Template",
"\n",
"Description",
":",
"Sample",
"/",
"template",
"for",
"a",
"normal",
"male",
"multisystem",
"exam",
".",
"\n",... | [
{
"char_end": 130,
"char_start": 124,
"text": "normal",
"token_end": 25,
"token_start": 24,
"type": "labvalue"
},
{
"char_end": 152,
"char_start": 131,
"text": "male multisystem exam",
"token_end": 28,
"token_start": 25,
"type": "test"
},
{
"char_end": 240... | train/69_20210604143823_Booma |
Sample Type / Medical Specialty : General Medicine Sample Name : Gen Med Consult - 33
Description : Patient with hypertension , dementia , and depression . ( Medical Transcription Sample Report )
MEDICAL PROBLEM LIST :
1 . Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006 .
2 . Dementia and depression .
3 . Hypertension .
4 . History of atrial fibrillation . The patient has been in sinus rhythm as of late . The patient is not anticoagulated due to fall risk .
5 . Glaucoma .
6 . Degenerative arthritis of her spine .
7 . GERD .
8 . Hypothyroidism .
9 . Chronic rhinitis ( the patient declines nasal steroids ) .
10 . Urinary urge incontinence .
11 . Chronic constipation .
12 . Diabetes type II , 2006 .
13 . Painful bunions on feet bilaterally .
CURRENT MEDICINES : Aspirin 81 mg p.o. daily , Cymbalta 60 mg p.o. daily , Diovan 80 mg p.o. daily , felodipine 5 mg p.o. daily , omeprazole 20 mg daily , Toprol-XL 100 mg daily , Levoxyl 50 mcg daily , Lantus insulin 12 units subcutaneously h.s . , simvastatin 10 mg p.o. daily , AyrGel to both nostrils twice daily , Senna S 2 tablets twice daily , Timoptic 1 drop both eyes twice daily , Tylenol 1000 mg 3 times daily , Xalatan 0.005% drops 1 drop both eyes at bedtime , and Tucks to rectum post BMs .
ALLERGIES : NO KNOWN DRUG ALLERGIES .
ACE INHIBITOR MAY HAVE CAUSED A COUGH .
CODE STATUS : Do not resuscitate , healthcare proxy , palliative care orders in place .
DIET : No added salt , no concentrated sweets , thin liquids .
RESTRAINTS : None . The patient has declined use of chair check and bed check .
INTERVAL HISTORY : Overall , the patient has been doing reasonably well . She is being treated for some hemorrhoids , which are not painful for her . There has been a note that she is constipated . Her blood glucoses have been running reasonably well in the morning , perhaps a bit on the high side with the highest of 188 . I see a couple in the 150s . However , I also see one that is in the one teens and a couple in the 120s range . She is not bothered by cough or rib pain . These are complaints , which I often hear about . Today , I reviewed Dr. Hudyncia's note from psychiatry . Depression responded very well to Cymbalta , and the plan is to continue it probably for a minimum of 1 year . She is not having problems with breathing . No neurologic complaints or troubles . Pain is generally well managed just with Tylenol .
PHYSICAL EXAMINATION :
Vitals : As in chart . The patient is pleasant and cooperative . She is in no apparent distress . Her lungs are clear to auscultation and percussion . Heart sounds regular to me . Abdomen : Soft . Extremities without any edema . At the rectum , she has a couple of large hemorrhoids , which are not thrombosed and are not tender .
ASSESSMENT AND PLAN :
1 . Hypertension , good control , continue current .
2 . Depression , well treated on Cymbalta . Continue .
3 . Other issues seem to be doing pretty well . These include blood pressure , which is well controlled . We will continue the medicines . She is clinically euthyroid . We check that occasionally . Continue Tylenol .
4 . For the bowels , I will increase the intensity of regimen there . I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink . I will try her on annulose and see how she does with that .
Keywords : general medicine , cerebrovascular , atrial fibrillation , chronic rhinitis , depression , hypertension , hemorrhoids , progress , | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"33",
"\n",
"Description",
":",
"Patient",
"with",
"hypertension",
",",
"dementia",
",",
"and",
"depression",
".",
"(",
"Medical",... | [
{
"char_end": 126,
"char_start": 114,
"text": "hypertension",
"token_end": 22,
"token_start": 21,
"type": "problem"
},
{
"char_end": 137,
"char_start": 129,
"text": "dementia",
"token_end": 24,
"token_start": 23,
"type": "problem"
},
{
"char_end": 154,
... | train/6_20210621151656_Hayden |
Sample Type / Medical Specialty: General Medicine
Sample Name: Perioperative Elevated Blood Pressure
Description: Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Perioperative elevated blood pressure.
PAST MEDICAL HISTORY:
1. Graves disease.
2. Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.
3. Diverticulosis.
4. GERD.
5. High blood pressure.
6. Prostatic hypertrophy, status post transurethral resection of the prostate.
PAST SURGICAL HISTORY: Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.
HISTORY OF PRESENTING COMPLAINT: This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today. Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking. On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No recent fever or general malaise.
ENT: Unremarkable.
RESPIRATORY: No cough or shortness of breath.
CARDIOVASCULAR: No chest pain.
GASTROINTESTINAL: No nausea or vomiting.
GENITOURINARY: The patient has prostatic hypertrophy, had laser surgery earlier today.
ENDOCRINE: Negative for diabetes, but positive for Graves disease.
MEDICATIONS: The patient takes Synthroid and aspirin. Aspirin had been discontinued about 1 week ago. He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.
PHYSICAL EXAMINATION:
GENERAL: A 71-year-old gentleman, not in acute distress.
CHEST: Clear to auscultation.
CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.
ABDOMEN: Benign.
EXTREMITIES: There is no swelling.
NEUROLOGICAL: The patient is alert and oriented x3. Examination is nonfocal.
ASSESSMENT AND PLAN:
1. Perioperative hypertension. We will restart lisinopril at half the previous dose. He will be on 20 mg p.o. daily. If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily. The patient should see his primary physician, Dr. Y in 2 weeks' time. If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.
2. Prostatic hypertrophy, status post laser surgery. The patient tolerated the procedure well.
3. History of Graves disease.
4. History of atrial fibrillation. The patient is in normal sinus rhythm.
DISPOSITION: The patient is stable to be discharged to home. Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.
Keywords:
general medicine, elevated blood pressure, paroxysmal atrial fibrillation, prostatic hypertrophy, rotator cuff repair, left knee arthroplasty, transurethral resection of prostate, blood pressure, blood, pressure, perioperative,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Perioperative",
"Elevated",
"Blood",
"Pressure",
"\n",
"Description",
":",
"Before",
"surgery",
",",
"the",
"patient",
"'s",
"blood",
"pressure",
"was",
"1... | [
{
"char_end": 100,
"char_start": 63,
"text": "Perioperative Elevated Blood Pressure",
"token_end": 16,
"token_start": 12,
"type": "problem"
},
{
"char_end": 158,
"char_start": 130,
"text": "the patient's blood pressure",
"token_end": 27,
"token_start": 22,
"type":... | train/71_20210112211703 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 30
Description: Patient was found to have decrease in mental alertness
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Mental changes today.
HISTORY OF PRESENT ILLNESS: This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range.
PAST MEDICAL HISTORY: Diabetes, hypertension.
PAST SURGICAL HISTORY: None.
FAMILY HISTORY: Unremarkable.
ALLERGIES: No known drug allergies.
MEDICATIONS: In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day.
SOCIAL HISTORY: The patient is a Mazatlan, Mexico resident, visiting her son here.
PHYSICAL EXAMINATION:
GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.
HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings.
HEART: Regular rate and rhythm, without murmur. Normal S1, S2.
LUNGS: Clear. No rales. No wheeze. Good excursion.
ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.
EXTREMITIES: No edema, clubbing, or cyanosis. No rash.
LABORATORY FINDINGS: On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates.
IMPRESSION:
1. Hypoglycemia due to not eating her meals on a regular basis.
2. Hypertension.
3. Renal insufficiency, may be dehydration, or diabetic nephropathy.
PLAN: Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.
Keywords:
general medicine, diabetic medication, diabetes, hypertension, hypoglycemia, renal insufficiency, diabetic nephropathy, dehydration, iv fluid, glucometer checks, decrease in mental alertness, blood pressure medication, mental alertness, blood pressure, diabetic, glucose, blood, pressure, medication, alertness,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"30",
"\n",
"Description",
":",
"Patient",
"was",
"found",
"to",
"have",
"decrease",
"in",
"mental",
"alertness",
"\n",
"(... | [
{
"char_end": 151,
"char_start": 123,
"text": "decrease in mental alertness",
"token_end": 29,
"token_start": 25,
"type": "problem"
},
{
"char_end": 131,
"char_start": 123,
"text": "decrease",
"token_end": 26,
"token_start": 25,
"type": "course"
},
{
"char... | train/71_20210604143824_Booma |
Sample Type/Medical Specialty : General Medicine
Sample Name : Headache - Office Visit
Description :
The patient with continued problems with her headaches. (Medical Transcription Sample Report) The patient returns to our office today because of continued problems with her headaches. She was started on Zonegran on her last visit and she states that initially she titrated upto 100 mg q.h.s. Initially felt that the Zonegran helped, but then the pain in her head returned. It is an area of tenderness and sensitivity in her left parietal area. It is a very localized pain. She takes Motrin 400 mg b.i.d., which helped. She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006. She was also never referred to the endocrine clinic to deal with her poor diabetes control. Her last hemoglobin A1c was 10.
PAST MEDICAL HISTORY : Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.
MEDICATIONS : Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.
PHYSICAL EXAMINATION :
Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds. On general exam she has an area of tenderness on palpation in the left parietal region of her scalp. Neurological exam is detailed on our H & P form. Her neurological exam is within normal limits.
IMPRESSION AND PLAN : For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy. If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica. We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested. She will be seeing Dr. XYZ for her neuropathies. We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.
Keywords : general medicine, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran, | [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Headache",
"-",
"Office",
"Visit",
"\n",
"Description",
":",
"\n",
"The",
"patient",
"with",
"continued",
"problems",
"with",
"her",
"headaches",
".",
"(... | [
{
"char_end": 72,
"char_start": 64,
"text": "Headache",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 158,
"char_start": 145,
"text": "her headaches",
"token_end": 28,
"token_start": 26,
"type": "problem"
},
{
"char_end": 237,
... | train/73_20210610044426_Booma |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary
Description: Patient had some cold symptoms, was treated as bronchitis with antibiotics.
(Medical Transcription Sample Report)
DISCHARGE DIAGNOSES:
1. Acute respiratory failure, resolved.
2. Severe bronchitis leading to acute respiratory failure, improving.
3. Acute on chronic renal failure, improved.
4. Severe hypertension, improved.
5. Diastolic dysfunction.
X-ray on discharge did not show any congestion and pro-BNP is normal.
SECONDARY DIAGNOSES:
1. Hyperlipidemia.
2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.
3. Remote history of carcinoma of the breast.
4. Remote history of right nephrectomy.
5. Allergic rhinitis.
HOSPITAL COURSE: This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization.
Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.
DISPOSITION: The patient has been discharged home.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Simvastatin 20 mg p.o. daily.
NEW MEDICATIONS:
1. Prednisone 20 mg p.o. daily for seven days.
2. Flonase nasal spray daily for 30 days.
Results for oximetry pending to evaluate the patient for need for home oxygen.
FOLLOW UP: The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.
Keywords:
discharge summary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Patient",
"had",
"some",
"cold",
"symptoms",
",",
"was",
"treated",
"as",
"bronchitis",
"with",
"antibio... | [
{
"char_end": 125,
"char_start": 107,
"text": "some cold symptoms",
"token_end": 22,
"token_start": 19,
"type": "problem"
},
{
"char_end": 152,
"char_start": 142,
"text": "bronchitis",
"token_end": 27,
"token_start": 26,
"type": "problem"
},
{
"char_end": ... | train/74_20210112211704 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Normal ENT Exam
Description: Sample normal ear, nose, mouth, and throat exam.
(Medical Transcription Sample Report)
EARS, NOSE, MOUTH AND THROAT: The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing.
Keywords:
general medicine, erythema, tympanic, mouth, throat, ears, mucosa, nose,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"ENT",
"Exam",
"\n",
"Description",
":",
"Sample",
"normal",
"ear",
",",
"nose",
",",
"mouth",
",",
"and",
"throat",
"exam",
".",
"\n",
"(",... | [
{
"char_end": 69,
"char_start": 63,
"text": "Normal",
"token_end": 13,
"token_start": 12,
"type": "labvalue"
},
{
"char_end": 78,
"char_start": 70,
"text": "ENT Exam",
"token_end": 15,
"token_start": 13,
"type": "test"
},
{
"char_end": 105,
"char_start... | train/74_20210604143824_Booma |
Chief Complaint
Ruby Holliday is a 63-year-old right-handed black female with probable MS based on difficulties with cognition and ambulation, MRI changes, and CSF with 2 OCB History of Present Illness She was last here on May 2011. She has not started on interferon yet. Her symptoms are still present, and have not improved. Her R leg drags at the end of the day. She walks to the bus to get to work and to the store. She had two falls since last seen, both outside on uneven ground. She doesn't note heat sensitivity. She has obtained the betaseron information, but not the medication. She is still taking thyroid replacement. She has cut her hours at work to 7 hours 4 days a week from 9 hours 5 days a week. She is having trouble making it through a full day. Her urinary frequency/urgency has improved. She still wears pads for minor accidents and only wakes up once per night to use the bathroom. She is not taking oxybutynin. Her symptoms began in about 2003 with right leg weakness.
On January 1, 2008, she was admitted to St. Luke's for an episode of numbness effecting the left axilla, arm, and leg. MRI shows lesions typical for MS, and blood studies have not shown an alternative diagnosis.
Allergies
1. Penicillins
Current Meds
1. Flovent HFA 44 MCG/ACT Inhalation Aerosol; INHALE 2 PUFFS EVERY 12 HOURS; Therapy: 13Nov2009 to (Evaluate: 17Feb2011) Requested for: 18Jan2011; Last Rx: 18Jan2011
2. Levoxyl 100 MCG Oral Tablet; TAKE 1 TABLET DAILY; Therapy: 23Jul2010 to (Evaluate: 17Aug2011) Requested for: 18Jul2011; Last Rx: 18Jul2011
3. ProAir HFA 108 (90 Base) MCG/ACT Inhalation Aerosol Solution; INHALE 2 PUFFS EVERY 4 HOURS AS NEEDED FOR COUGH AND WHEEZE; Therapy: 13Nov2009 to (Evaluate: 22Aug2011) Requested for: 24May2011; Last Rx: 24May2011
4. Accu-Chek Softclix Lancets Miscellaneous; USE AS DIRECTED; Therapy: 17Mar2010 to (Last Rx: 17Mar2010) Requested for: 17Mar2010
5. Pantoprazole Sodium 40 MG Oral Tablet Delayed Release; TAKE 1 TABLET DAILY; Therapy: 27Apr2010 - Requested for: 04May2011; Last Rx: 04May2011; Status: NEED INFORMATION - Problem
6. Rebif 44 MCG/0.5ML Subcutaneous Solution; INJECT 0.5 ML 3 TIMES WEEKLY AS DIRECTED; Therapy: 04May2011 to
Past Medical History
primary syphilis about 1980, treated
Family History
1. Paternal history of Asthma V17.5
2. Maternal history of Hypertension V17.49
Social History
"Marital History - Divorced V61.0"
Never Smoked
Denied "Alcohol" Alcohol "Behavioral History"
Drug Use "Tobacco Use" Tobacco Use
She works as a cashier in a store. She uses the bus, and has to walk up to 5 blocks to the bus stop. She has to walk 8 blocks to the store, and has to carry things back with her.
Review of Systems
Complete - Female
Neuro Emphasis:
Cardiovascular, respiratory and gastrointestinal review of systems are normal.
Vitals UTP Adult Vital Signs [ Data Includes: Current Encounter ] 17Aug2011 09:43AM BMI Calculated: 25.07 BSA Calculated: 1.62 Height: 5 ft 2 in Weight: 136 lb 4 oz Systolic: 134 Diastolic: 85 Heart Rate: 71
Physical Exam
Constitutional
General Appearance: Normal.
Patient was not observed to be obese.
Throat, Neck, and Back Neck: Normal.
Oropharynx: Normal.
Pulmonary
Auscultation of lungs: Normal.
Cardiovascular
Auscultation of heart: Normal.
Mental Status: A mental status exam was performed and was normal.
Language: No dysphasia/aphasia was observed.
Cranial Nerves:
Cranial nerves II: visual acuity and visual fields were intact.
Cranial nerves III, IV, and VI: the extraocular motions were intact.
Cranial nerves V: sensation to the face and masseter strength were intact.
Cranial nerves VII: facial strength was intact bilaterally.
Cranial nerves VIII: hearing was intact.
Cranial nerves IX and X: there was normal movement of the soft palate and normal gag. Cranial nerves XI: shoulder shrug was intact bilaterally.
Cranial nerves XII: there was no tongue deviation with protrusion.
Motor Strength: Upper Extremities Normal
Lower Extremities: (4 to 5-, weaker on R).
Motor Survey: both legs were hypertonic. R worse
Reflexes: the deep tendon reflexes were abnormal
Biceps: right 3+ andleft 3+. Triceps: right 3+ andleft 3+.
Brachioradialis: right 3+ andleft 3+. Patella: right 4+ andleft 3+.
Ankle Jerk: right 3+ andleft 3+.
Babinski reflex absent on the rightandabsent on the left.
Ankle Clonus 1-2 beats present on the right and 1-2 beats present on the left.
Gait: spastic bilaterally. Decreased response to touch stimulation Decreased response to stimulation by vibration. (5, 5, 2, 2). Decreased response to pain and temperature stimulation on the right side.
Results/Results/Data
1/2011 CBC, LFT, Fe, and TIBC were normal.
Results/Assessment
1. Multiple Sclerosis 340
2. Dyspepsia 536.8
Plan
1. Pantoprazole Sodium 40 MG Oral Tablet Delayed Release; TAKE 1 TABLET DAILY; Therapy: 17Aug2011 to (Evaluate: 13Feb2012); Last Rx: 17Aug2011
Ms Holliday has relapsing-remitting MS. She has still not started rebif. We discussed the risks of this. She is concerned it will make her too tired to work. I encouraged her to start the medication.
- - start rebif
- - CBC, LFT
- - rtc 3 months.
- - forms for short term disability
Attending Note
Signatures Electronically signed by: JOHN LINDSEY, M.D.;
Aug 17 2011 3:16PM (Author) | [
"Chief",
"Complaint",
"\n",
"Ruby",
"Holliday",
"is",
"a",
"63",
"-",
"year",
"-",
"old",
"right",
"-",
"handed",
"black",
"female",
"with",
"probable",
"MS",
"based",
"on",
"difficulties",
"with",
"cognition",
"and",
"ambulation",
",",
"MRI",
"changes",
"... | [
{
"char_end": 87,
"char_start": 79,
"text": "probable",
"token_end": 19,
"token_start": 18,
"type": "uncertain"
},
{
"char_end": 90,
"char_start": 88,
"text": "MS",
"token_end": 20,
"token_start": 19,
"type": "problem"
},
{
"char_end": 142,
"char_start... | train/74_20210610044426_Booma |
Pain Clinuc Medical Summasy Patient Detail for GLENDA STEWART MRN: 2141761 Contact GLENDA STEWART Date Of Birth December 28, 1964 Address 5106 MALMED ROAD
6101 ANTOINE DRIVE
HOUSTON, TX 77033 Gender Female Marital Status (281)382-4600 (Home phone) Language English - preferred Reason for Referral
No Reason for Referral was given.
Hi Hisy of Present Illness
No HPI available.
Problems f Normal Routine Hi Hisy And PhytutionAdult (V70.0); (Active)
f Normal Routine Hi Hisy And PhytutionAdult (V70.0); (Active)
f Closed Fracture Of The Proximal End Of The Humerus (812.00); (Active)
f Open Fracture Of The Medial Malleolus (824.1); (Active) f Shoulder Dislocation (831.00); (Active)
MedicaHion
f No Active MedicaHions
Allergies and Adverse Reactions
f No Known Drug Allergies (Active)
Past Medical Hi Hisy
f Hi Hisy of Anxiety (Symptom) (300.00); (Resolved)
Proceduses
Proceduse Proceduse Date Date Completed Status Ankle Surgery - - Resolved Advance Directives f No Advance Directives available.
Encounters f AUDIT 03/05/2013
f FUP, Provider: JONES,WILLIAM, Status: Pen, Time: 10:00 AM 04/22/2013
Healthcare Providers
Ambulatisy Health Care Facilities SYED NASIR Address: UNK
(713)704-7246 (Work phone) Patient Contacts
Emergency Contact: SHERRITA STEWART , (832)216-3053 (Home phone) Document Details SUMMARIZATION OF EPISODE NOTE Encounter March 5, 2013 12:08+0000 From Enterprise EHR 11.200.4288.9085 Site Pain Clinuc
6411 Fannin, 1 RoberHson
Houston, TX 77031
(713)704-7246 (Work phone) Created March 5, 2013 12:08-0600 By SYED NASIR | [
"Pain",
"Clinuc",
"Medical",
"Summasy",
"Patient",
"Detail",
"for",
"GLENDA",
"STEWART",
"MRN",
":",
"2141761",
"Contact",
"GLENDA",
"STEWART",
"Date",
"Of",
"Birth",
"December",
"28",
",",
"1964",
"Address",
"5106",
"MALMED",
"ROAD",
"\n",
"6101",
"ANTOINE",
... | [
{
"char_end": 561,
"char_start": 511,
"text": "Closed Fracture Of The Proximal End Of The Humerus",
"token_end": 117,
"token_start": 108,
"type": "problem"
},
{
"char_end": 561,
"char_start": 534,
"text": "Proximal End Of The Humerus",
"token_end": 117,
"token_start":... | train/75_20200709164917_Atieh |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 13
Description: Sepsis due to urinary tract infection.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient states she is feeling a bit better.
OBJECTIVE:
VITAL SIGNS: Temperature is 95.4. Highest temperature recorded over the past 24 hours is 102.1.
CHEST: Examination of the chest is clear to auscultation.
CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.
ABDOMEN: Benign. Right renal angle is tender. Bowel sounds are positive.
EXTREMITIES: There is no swelling.
NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.
LABORATORY DATA: White count is down from 35,000 to 15.5. Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000. BUN is down to 22, creatinine is within normal limits.
ASSESSMENT AND PLAN:
1. Sepsis due to urinary tract infection. Urine culture shows Escherichia coli, resistant to Levaquin. We changed to doripenem.
2. Urinary tract infection, we will treat with doripenem, change Foley catheter
3. Hypotension. Resolved, continue intravenous fluids.
4. Ischemic cardiomyopathy. No evidence of decompensation, we with monitor.
5. Diabetes type 2. Uncontrolled. Continue insulin sliding scale.
6. Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.
7. History of coronary artery disease. Troponin indeterminate. Cardiologist intends no further workup. Continue medical treatment. Most likely troponin is secondary to impaired clearance.
Keywords:
general medicine, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Progress",
"Note",
"-",
"13",
"\n",
"Description",
":",
"Sepsis",
"due",
"to",
"urinary",
"tract",
"infection",
".",
"\n",
"(",
"Medical"... | [
{
"char_end": 109,
"char_start": 103,
"text": "Sepsis",
"token_end": 22,
"token_start": 21,
"type": "problem"
},
{
"char_end": 140,
"char_start": 117,
"text": "urinary tract infection",
"token_end": 27,
"token_start": 24,
"type": "problem"
},
{
"char_end":... | train/76_20210112211704 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Female Exam Template - 1
Description: An example/template for a routine normal female physical exam.
(Medical Transcription Sample Report)
PHYSICAL EXAMINATION
GENERAL: The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.
HEAD: Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema, hemorrhages or exudates with normal vessels.
EARS: The ear canals are patent without edema, exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact.
NOSE: Without deformity, bleeding or discharge. No septal hematoma is noted.
ORAL CAVITY: No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard.
NECK: No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline.
CHEST: Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest.
LUNGS: Clear to auscultation bilaterally. No rales, rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields.
HEART: Regular rate and rhythm. No murmur. No S3, S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal.
ABDOMEN: Soft, nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted.
RECTAL: Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative.
GENITOURINARY: External genitalia without erythema, exudate or discharge. Vaginal vault is without discharge. Cervix is of normal color without lesion. The os is closed. There is no bleeding noted. Uterus is noted to be of normal size and nontender. No cervical motion tenderness is seen. No masses are palpated. The adnexa are without masses or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted.
SKIN: No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia, bulla or ecchymosis.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen.
PSYCHIATRIC: The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal.
Keywords:
general medicine, atraumatic, normocephalic, grossly intact, chest, percussion, lungs, palpated, gait, sclerae, edema, discharge, extremities, memory, exudates, erythema, auscultated, tenderness, signs,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"Female",
"Exam",
"Template",
"-",
"1",
"\n",
"Description",
":",
"An",
"example",
"/",
"template",
"for",
"a",
"routine",
"normal",
"female",
... | [
{
"char_end": 69,
"char_start": 63,
"text": "Normal",
"token_end": 13,
"token_start": 12,
"type": "labvalue"
},
{
"char_end": 81,
"char_start": 70,
"text": "Female Exam",
"token_end": 15,
"token_start": 13,
"type": "test"
},
{
"char_end": 148,
"char_st... | train/78_20210604143825_Booma |
Sample Type / Medical Specialty: General Medicine
Sample Name: Normal ENT Exam - 1
Description: Sample normal ear, nose, mouth, and throat exam.
(Medical Transcription Sample Report)
EARS, NOSE, MOUTH AND THROAT
EARS/NOSE: The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. The tympanic membranes are without disruption or infection. Hearing intact bilaterally to normal level speech. Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. The septum is without acute traumatic lesions or disruption. The turbinates are without abnormal swelling. There is no unusual rhinorrhea or bleeding.
LIPS/TEETH/GUMS: The lips are without infection, mass lesion or traumatic lesions. The teeth are intact without obvious signs of infection. The gingivae are normal to palpation and inspection.
OROPHARYNX: The oral mucosa is normal. The salivary glands are without swelling. The hard and soft palates are intact. The tongue is without masses or swelling with normal movement. The tonsils are without inflammation. The posterior pharynx is without mass lesion with good patent oropharyngeal airway.
Keywords:
general medicine, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"ENT",
"Exam",
"-",
"1",
"\n",
"Description",
":",
"Sample",
"normal",
"ear",
",",
"nose",
",",
"mouth",
",",
"and",
"throat",
"exam",
".",
... | [
{
"char_end": 109,
"char_start": 103,
"text": "normal",
"token_end": 22,
"token_start": 21,
"type": "labvalue"
},
{
"char_end": 143,
"char_start": 110,
"text": "ear, nose, mouth, and throat exam",
"token_end": 31,
"token_start": 22,
"type": "test"
},
{
"ch... | train/80_20210604143825_Booma |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: COPD - Discharge Summary
Description: A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.
PAST MEDICAL HISTORY: Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol.
PHYSICAL EXAMINATION: Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields.
LABORATORY STUDIES: Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7.
HOSPITAL COURSE: He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease and acute asthmatic bronchitis.
COMPLICATIONS: None.
DISCHARGE CONDITION: Guarded.
DISCHARGE PLAN: Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days.
Keywords:
discharge summary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"COPD",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"A",
"67",
"-",
"year",
"-",
"old",
"male",
"with",
"COPD",
"and",
"history",
"of",
"b... | [
{
"char_end": 68,
"char_start": 64,
"text": "COPD",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 130,
"char_start": 126,
"text": "COPD",
"token_end": 28,
"token_start": 27,
"type": "problem"
},
{
"char_end": 158,
"char_start":... | train/82_20210112211705 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Hypertension - Consult
Description: An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.
PAST CARDIAC HISTORY: She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.
MEDICATIONS ON ADMISSION:
1. Multivitamin p.o. daily.
2. Aspirin 325 mg once a day.
3. Lisinopril 40 mg once a day.
4. Felodipine 10 mg once a day.
5. Klor-Con 20 mEq p.o. b.i.d.
6. Omeprazole 20 mg p.o. daily presumably for GERD.
7. MiraLax 17 g p.o. daily.
8. Lasix 20 mg p.o. daily.
ALLERGIES: PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.
FAMILY HISTORY: She states her brother died of an MI suddenly in his 50s.
SOCIAL HISTORY: She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.
REVIEW OF SYSTEMS: She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.
PHYSICAL EXAM: Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.
DIAGNOSTIC STUDIES/LAB DATA: Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.
EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.
IMPRESSION: She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.
Keywords:
general medicine, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Hypertension",
"-",
"Consult",
"\n",
"Description",
":",
"An",
"84",
"-",
"year",
"-",
"old",
"woman",
"with",
"a",
"history",
"of",
"hypertension",
",... | [
{
"char_end": 75,
"char_start": 63,
"text": "Hypertension",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 150,
"char_start": 138,
"text": "hypertension",
"token_end": 30,
"token_start": 29,
"type": "problem"
},
{
"char_end": 182,
... | train/82_20210604143826_Booma |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Ectopic Pregnancy - Discharge Summary
Description: A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.
HOSPITAL COURSE: The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.
FINAL DIAGNOSES:
1. Right ruptured ectopic pregnancy with hemoperitoneum.
2. Anemia secondary to blood loss.
PLAN: The patient will be dismissed on pain medication and iron therapy.
Keywords:
discharge summary, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Ectopic",
"Pregnancy",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"A",
"31",
"-",
"year",
"-",
"old",
"white",
"female",
"admitted",
"to",
... | [
{
"char_end": 81,
"char_start": 64,
"text": "Ectopic Pregnancy",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 183,
"char_start": 172,
"text": "pelvic pain",
"token_end": 35,
"token_start": 33,
"type": "problem"
},
{
"char_end": 17... | train/83_20210112211705 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Neonatal Discharge Summary
Description: The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.
(Medical Transcription Sample Report)
HOSPITAL COURSE: The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5:57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate. Baby was born with Apgar scores of 8 and 9 at delivery. Fluid was cleared. Nuchal cord x1. Prenatal was at ABC Valley. Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive. Baby was suctioned on perineum with good support. The baby was admitted to the NICU for prematurity and to rule out sepsis. Baby's cry was good. Color, tone, and __________ mild retractions. CBC, CRP, blood cultures were done. IV fluids of D10 at a rate of 6 mL an hour. Ampicillin and gentamicin were started via protocol. At the time of admission, the patient was stable on room air and has feeding issues. Baby was fed EBM 22 and NeoSure per os. Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours. The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced. Also, the baby was able to suck properly and was tolerating feeds. The baby was fed EBM 22 and NeoSure was added a day before discharge. At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.
ADMISSION DIAGNOSES: Respiratory distress, rule out sepsis and prematurity.
DISCHARGE DIAGNOSES: Stable, ex-34-week preemie.
Pediatrician after discharge will be Dr. X.
DISCHARGE INSTRUCTIONS: To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006. CPR teaching was completed on 08/11/2006 to parents. Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed. Ad lib feeding on demand.
Keywords:
discharge summary, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Neonatal",
"Discharge",
"Summary",
"\n",
"Description",
":",
"The",
"patient",
"is",
"an",
"1812",
"g",
"baby",
"boy",
"born",
"by",
"vaginal",
"deliver... | [
{
"char_end": 162,
"char_start": 146,
"text": "vaginal delivery",
"token_end": 30,
"token_start": 28,
"type": "treatment"
},
{
"char_end": 258,
"char_start": 248,
"text": "C-sections",
"token_end": 55,
"token_start": 52,
"type": "treatment"
},
{
"char_end"... | train/84_20210604143826_Booma |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Kawasaki Disease - Discharge Summary
Description: This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSIS: Kawasaki disease.
DISCHARGE DIAGNOSIS: Kawasaki disease, resolving.
HOSPITAL COURSE: This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.
DISCHARGE ACTIVITIES: Ad-lib.
DISCHARGE DIET: PO ad-lib.
DISCHARGE MEDICATIONS: Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.
Keywords:
discharge summary, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Kawasaki",
"Disease",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"This",
"is",
"a",
"14",
"-",
"month",
"-",
"old",
"baby",
"boy",
"Caucas... | [
{
"char_end": 80,
"char_start": 64,
"text": "Kawasaki Disease",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 184,
"char_start": 173,
"text": "presumptive",
"token_end": 36,
"token_start": 35,
"type": "uncertain"
},
{
"char_end": 2... | train/88_20210604143828_Booma |
Sample Type / Medical Specialty: General Medicine
Sample Name: Consult - Coronary Artery Disease
Description: Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Coronary artery disease (CAD), prior bypass surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness. No symptoms of chest pain or shortness of breath.
His history from cardiac standpoint as mentioned below.
CORONARY RISK FACTORS: History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive.
FAMILY HISTORY: Positive for coronary artery disease.
SURGICAL HISTORY: Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.
MEDICATIONS:
1. Metformin.
2. Prilosec.
3. Folic acid.
4. Flomax.
5. Metoprolol.
6. Crestor.
7. Claritin.
ALLERGIES: DEMEROL, SULFA.
PERSONAL HISTORY: He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.
PAST MEDICAL HISTORY: Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors.
HEENT: No history of cataract or glaucoma.
CARDIOVASCULAR: As above.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena.
UROLOGICAL: Frequency, urgency.
MUSCULOSKELETAL: No muscle weakness.
SKIN: None significant.
NEUROLOGICAL: No TIA or CVA. No seizure disorder.
PSYCHOLOGICAL: No anxiety or depression.
ENDOCRINE: As above.
HEMATOLOGICAL: None significant.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.
HEENT: Atraumatic, normocephalic.
NECK: Veins flat. No significant carotid bruits.
LUNGS: Air entry bilaterally fair.
HEART: PMI displaced. S1 and S2 regular.
ABDOMEN: Soft, nontender. Bowel sounds present.
EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis.
CNS: Benign.
EKG: Normal sinus rhythm, incomplete right bundle-branch block.
LABORATORY DATA: H&H stable, BUN and creatinine within normal limits.
IMPRESSION:
1. History of coronary artery disease, prior bypass surgery, angioplasty, significant shortness of breath.
2. Fever with possible urinary tract infection versus prostatitis.
3. Hypertension, hyperlipidemia, diabetes mellitus.
4. Contemplated prostate surgery down the road.
RECOMMENDATION:
1. From cardiac standpoint, medical management including antibiotic for his fever.
2. We will consider cardiac workup in terms of to rule out ischemia and patency of the graft. If he decides to go for surgery, I would like him to wait until the fever has subsided and is well under control. Discussed with the patient the plan of care, consent was obtained. All the questions answered in detail.
Keywords:
general medicine, coronary artery disease, cad, hypertension, diabetes mellitus, cholesterol, bypass, prior bypass surgery, urinary tract infection, fatigue and tiredness, shortness of breath, elevated psa, surgery, artery, cardiac, infection, fever, coronary,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Consult",
"-",
"Coronary",
"Artery",
"Disease",
"\n",
"Description",
":",
"Coronary",
"artery",
"disease",
",",
"prior",
"bypass",
"surgery",
".",
"The",
... | [
{
"char_end": 96,
"char_start": 73,
"text": "Coronary Artery Disease",
"token_end": 17,
"token_start": 14,
"type": "problem"
},
{
"char_end": 88,
"char_start": 73,
"text": "Coronary Artery",
"token_end": 16,
"token_start": 14,
"type": "bodyloc"
},
{
"char_... | train/89_20210112211706 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 28
Description: The patient brought in by EMS with a complaint of a decreased level of consciousness.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days.
PAST MEDICAL HISTORY: Parkinson disease.
MEDICATIONS: Requip, Neurontin, Sinemet, Ambien, and Xanax.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife.
PHYSICAL EXAMINATION:
GENERAL: The patient is cachectic and dehydrated. The patient is lethargic at this time. He answers minimally to only a few questions. He is not able to follow commands at this time.
HEENT: He has 2 lacerations on the face, which are sutured. The first one is in the middle of his forehead, and the second one is a lip laceration on his upper lip. Pupils are reactive to light. Extraocular movements are intact. Mucous membranes are dry.
NECK: Supple. No thyromegaly. No lymphadenopathy.
HEART: S1, S2 heard. No murmurs.
LUNGS: Clear with clear breath sounds.
ABDOMEN: Soft and nontender. Positive bowel sounds.
EXTREMITIES: No edema.
NEUROLOGIC: I cannot assess at this time.
DIAGNOSTIC STUDIES: An EKG showed a normal sinus rhythm at a rate of 77 beats per minute. Urine showed negative for a drug screen. His UA showed 8+ WBCs and some RBCs. Specific gravity was increased at more than 1.03. A comprehensive panel was negative except for a potassium of 3.4. A CBC was normal except for elevation of the white count at 12.2 and neutrophils 89%.
ASSESSMENT:
1. Recent fall.
2. Altered mental status, possible exacerbation of Parkinson.
3. Dehydration, poor p.o. intake.
4. Suspect elderly abuse.
PLAN: We will admit the patient to the regular medical floor. We will give him IV fluids. We will restart his Sinemet.
Keywords:
general medicine, level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"28",
"\n",
"Description",
":",
"The",
"patient",
"brought",
"in",
"by",
"EMS",
"with",
"a",
"complaint",
"of",
"a",
"de... | [
{
"char_end": 164,
"char_start": 149,
"text": "decreased level",
"token_end": 33,
"token_start": 31,
"type": "course"
},
{
"char_end": 181,
"char_start": 168,
"text": "consciousness",
"token_end": 35,
"token_start": 34,
"type": "problem"
},
{
"char_end": 3... | train/8_20210604143807_Hayden |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Mastoiditis - Discharge Summary
Description: Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.
(Medical Transcription Sample Report)
DISCHARGE DIAGNOSES:
1. Suspected mastoiditis ruled out.
2. Right acute otitis media.
3. Severe ear pain resolving.
HISTORY OF PRESENT ILLNESS: The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well.
DISCHARGE PHYSICAL EXAMINATION:
GENERAL: The patient is alert, in no respiratory distress.
VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.
HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.
NECK: Supple.
CHEST: Clear breath sounds.
CARDIAC: Normal S1, S2 without murmur.
ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness.
SKIN: Warm and well perfused.
DISCHARGE WEIGHT: 38.7 kg.
DISCHARGE CONDITION: Good.
DISCHARGE DIET: Regular as tolerated.
DISCHARGE MEDICATIONS:
1. Ciprodex Otic Solution in the right ear twice daily.
2. Augmentin 500 mg three times daily x10 days.
FOLLOW UP:
1. Dr. Y in one week (ENT).
2. The primary care physician in 2 to 3 days.
TIME SPENT: Approximate discharge time is 28 minutes.
Keywords:
discharge summary, acute otitis media, ear pain, mastoiditis, otitis media, discharge, ear,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Mastoiditis",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Suspected",
"mastoiditis",
"ruled",
"out",
",",
"right",
"acute",
"otitis",
"media",
... | [
{
"char_end": 75,
"char_start": 64,
"text": "Mastoiditis",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 118,
"char_start": 109,
"text": "Suspected",
"token_end": 20,
"token_start": 19,
"type": "uncertain"
},
{
"char_end": 130,
... | train/90_20210604143828_Booma |
Sample Type / Medical Specialty: General Medicine
Sample Name: Consult - Stasis Ulcer
Description: Nonhealing right ankle stasis ulcer. A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery.
(Medical Transcription Sample Report)
REASON FOR THE CONSULT: Nonhealing right ankle stasis ulcer.
HISTORY OF PRESENT ILLNESS: This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer. There is a concern that the patient had a low-grade fever of 100.2 early this morning. The patient otherwise feels well. He was not even aware of the fever. He does have some ankle pain, worse on the right than the left. Old medical records were reviewed. He has multiple hospitalizations for leg cellulitis. Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past. Klebsiella and Enterobacter have also grown in the few wound cultures at some point. The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No malaise. Positive recent low-grade fevers. No chills.
HEENT: No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion. No sore throat.
CARDIAC: No chest pain or cough.
GASTROINTESTINAL: No nausea, vomiting or diarrhea.
All other systems were reviewed and were negative.
PAST MEDICAL HISTORY: Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.
SOCIAL HISTORY: The patient admits to heavy alcohol drinking in the past, quit several years ago. He is also a former cigarette smoker, quit several years ago.
ALLERGIES: None known.
CURRENT MEDICATIONS: Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.
PHYSICAL EXAMINATION:
CONSTITUTIONAL/VITAL SIGNS: Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.
GENERAL APPEARANCE: The patient is awake, alert, and not in cardiorespiratory distress. Height 6 feet 1.5 inches, body weight 125.26 kilos.
EYES: Pink conjunctivae, anicteric sclerae. Pupils equal, brisk reaction to light.
EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.
NECK: No palpable neck masses. Thyroid is not enlarged on inspection.
RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.
CARDIOVASCULAR: Regular cardiac rhythm. No thrills or rubs.
GASTROINTESTINAL: Normoactive bowel sounds. Soft. No guarding or rigidity.
LYMPHATIC: No cervical lymphadenopathy.
MUSCULOSKELETAL: Good range of motion of upper and lower extremities.
SKIN: There is hyperpigmentation involving the distal calf of both legs. There is an open wound on the right medial
malleolar area measuring 9 x 5cm with minimal serous drainage. Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg. There is warmth, but minimal tenderness on palpation of this area. There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm. Wound edges are poorly defined.
PSYCHIATRIC: Appropriate mood and affect, oriented x3. Fair judgment and insight.
LABORATORY RESULTS: White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000. BUN and creatinine 9.2/0.52. Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6. One wound culture from right leg wound culture from 01/27/09 noted with young growth. Left leg wound culture from 01/27/09 also with young growth.
RADIOLOGY: Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus. No absolute findings.
IMPRESSION:
1. Fevers.
2. Right leg/ankle cellulitis.
3. Chronic recurrent bilateral ankle venous ulcers.
4. Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.
5. Hypertension.
RECOMMENDATIONS:
1. We have ordered 2 sets of blood cultures.
2. Agree with daptomycin and Primaxin IV.
3. Follow up result of wound cultures.
4. I will order an MRI of the right ankle to check for underlying osteomyelitis.
Additional ID recommendations as appropriate upon followup.
Keywords:
general medicine, fevers, cellulitis, venous ulcers, bipedal edema, stasis ulcer, wound cultures, wound, ankle, ulcer, hypertension, ulcers, stasis, chronic,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Consult",
"-",
"Stasis",
"Ulcer",
"\n",
"Description",
":",
"Nonhealing",
"right",
"ankle",
"stasis",
"ulcer",
".",
"A",
"52",
"-",
"year",
"-",
"old",... | [
{
"char_end": 85,
"char_start": 73,
"text": "Stasis Ulcer",
"token_end": 16,
"token_start": 14,
"type": "problem"
},
{
"char_end": 134,
"char_start": 99,
"text": "Nonhealing right ankle stasis ulcer",
"token_end": 24,
"token_start": 19,
"type": "problem"
},
{
... | train/92_20210112211706 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Normal ROS Template - 1
Description: There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing.
(Medical Transcription Sample Report)
REVIEW OF SYSTEMS
There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. There is no shortness of breath and no cough or hemoptysis. No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools. No dysuria, hematuria or excessive urination. No muscle weakness or tenderness. No new numbness or tingling. No arthralgias or arthritis. There are no rashes. No excessive fatigability, loss of motor skills or sensation. No changes in hair texture, change in skin color, excessive or decreased appetite. No swollen lymph nodes or night sweats. No headaches. The rest of the review of systems is negative.
Keywords:
general medicine, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neck,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Normal",
"ROS",
"Template",
"-",
"1",
"\n",
"Description",
":",
"There",
"was",
"no",
"weight",
"loss",
",",
"fevers",
",",
"chills",
",",
"sweats",
... | [
{
"char_end": 112,
"char_start": 110,
"text": "no",
"token_end": 23,
"token_start": 22,
"type": "negation"
},
{
"char_end": 124,
"char_start": 113,
"text": "weight loss",
"token_end": 25,
"token_start": 23,
"type": "problem"
},
{
"char_end": 132,
"char... | train/98_20210112211707 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 11
Description: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSES: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.
DISCHARGE DIAGNOSES: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.
PROCEDURE: Laparoscopic cholecystectomy.
SERVICE: Surgery.
HISTORY OF PRESENT ILLNESS: Ms. ABC is a 57-year-old woman. She suffers from morbid obesity. She also has diabetes and obstructive sleep apnea. She was evaluated in the Bariatric Surgical Center for placement of a band. During her workup, she was noted to have evidence of cholelithiasis. It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band. The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438. She was admitted to the hospital for treatment of her hyperglycemia.
HOSPITAL COURSE: Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. She underwent the procedure. She tolerated without difficulty. She was recovered in the Postoperative Care Unit and then returned to the floor. Her blood sugar postprocedure was noted to be 233. She was started back on a sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure.
DISCHARGE INSTRUCTIONS: To return to the Medifast diet. To continue with her blood glucose. She needs to follow up with Dr. B, and she will see me next week on Friday. We will determine if we will proceed with her lap band at that time. She may shower. She needs to keep her wounds clean and dry. No heavy lifting. No driving on narcotic pain medicines. She needs to continue with her CPAP machine and continue to monitor her sugars.
Keywords:
discharge summary, medifast, hyperglycemia, laparoscopic cholecystectomy, medifast diet, cholecystitis, cholelithiasis, diabetes mellitus, hypertension, morbid obesity, obstructive sleep apnea, sleep apnea, diabetes,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"11",
"\n",
"Description",
":",
"Hyperglycemia",
",",
"cholelithiasis",
",",
"obstructive",
"sleep",
"apnea",
",",
"diabetes",
... | [
{
"char_end": 113,
"char_start": 100,
"text": "Hyperglycemia",
"token_end": 20,
"token_start": 19,
"type": "problem"
},
{
"char_end": 129,
"char_start": 115,
"text": "cholelithiasis",
"token_end": 22,
"token_start": 21,
"type": "problem"
},
{
"char_end": 1... | train/done_sample_1240 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Knee Osteoarthrosis - Discharge Summary
Description: A 66-year-old female with knee osteoarthrosis who failed conservative management.
(Medical Transcription Sample Report)
PRINCIPAL DIAGNOSIS: Knee osteoarthrosis.
PRINCIPAL PROCEDURE: Total knee arthroplasty.
HISTORY AND PHYSICAL: A 66-year-old female with knee osteoarthrosis. Failed conservative management. Risks and benefits of different treatment options were explained. Informed consent was obtained.
PAST SURGICAL HISTORY: Right knee surgery, cosmetic surgery, and carotid sinus surgery.
MEDICATIONS: Mirapex, ibuprofen, and Ambien.
ALLERGIES: QUESTIONABLE PENICILLIN ALLERGIES.
PHYSICAL EXAMINATION: GENERAL: Female who appears younger than her stated age. Examination of her gait reveals she walks without assistive devices.
HEENT: Normocephalic and atraumatic.
CHEST: Clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft.
EXTREMITIES: Grossly neurovascularly intact.
HOSPITAL COURSE: The patient was taken to the operating room (OR) on 03/15/2007. She underwent right total knee arthroplasty. She tolerated this well. She was taken to the recovery room. After uneventful recovery room course, she was brought to regular surgical floor. Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated. Routine postoperative antibiotics were administered. Hemovac drain was discontinued on postoperative day #2. Physical therapy was initiated. Continuous passive motion (CPM) was also initiated. She was able to spontaneously void. She transferred to oral pain medication. Incision remained clean, dry, and intact during the hospital course. No pain with calf squeeze. She was felt to be ready for discharge home on 03/19/2007.
DISPOSITION: Discharged to home.
FOLLOW UP: Follow up with Dr. X in one week. Prescriptions were written for Percocet and Coumadin.
INSTRUCTIONS: Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.
Keywords:
discharge summary, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Knee",
"Osteoarthrosis",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"A",
"66",
"-",
"year",
"-",
"old",
"female",
"with",
"knee",
"osteoarth... | [
{
"char_end": 83,
"char_start": 64,
"text": "Knee Osteoarthrosis",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 68,
"char_start": 64,
"text": "Knee",
"token_end": 13,
"token_start": 12,
"type": "bodyloc"
},
{
"char_end": 162,
... | train/done_sample_1274 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Cut on Foot - ER Visit
Description: Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Cut on foot.
HISTORY OF PRESENT ILLNESS: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints.
PAST MEDICAL HISTORY: Asthma.
CURRENT MEDICATION: Albuterol.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is a smoker.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. Oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well-nourished, well-developed, the patient appears to be healthy. The patient is calm and comfortable in no acute distress and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body.
EMERGENCY DEPARTMENT COURSE: The patient had antibiotic ointment and a bandage applied to his foot.
DIAGNOSES:
1. A 4-MM LACERATION TO THE RIGHT FOOT.
2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED.
CONDITION UPON DISPOSITION: Stable.
DISPOSITION: To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.
Keywords:
general medicine, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Cut",
"on",
"Foot",
"-",
"ER",
"Visit",
"\n",
"Description",
":",
"Patient",
"had",
"a",
"piece",
"of",
"glass",
"fall",
"on",
"to",
"his",
"right",
... | [
{
"char_end": 74,
"char_start": 63,
"text": "Cut on Foot",
"token_end": 15,
"token_start": 12,
"type": "problem"
},
{
"char_end": 74,
"char_start": 70,
"text": "Foot",
"token_end": 15,
"token_start": 14,
"type": "bodyloc"
},
{
"char_end": 153,
"char_st... | train/done_sample_2747 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Pneumonia - Discharge Summary
Description: Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSES:
1. Pneumonia, failed outpatient treatment.
2. Hypoxia.
3. Rheumatoid arthritis.
DISCHARGE DIAGNOSES:
1. Atypical pneumonia, suspected viral.
2. Hypoxia.
3. Rheumatoid arthritis.
4. Suspected mild stress-induced adrenal insufficiency.
HOSPITAL COURSE: This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. She was seen on multiple occasions at Urgent Care and in her physician's office. Initial x-ray showed some mild diffuse patchy infiltrates. She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin. Her O2 saturations drifted downward. They were less than 88% when active; at rest, varied between 88% and 92%. Decision was made because of failed outpatient treatment of pneumonia. Her medical history is significant for rheumatoid arthritis. She is on 20 mg of methotrexate every week as well as Remicade every eight weeks. Her last dose of Remicade was in the month of June. Hospital course was relatively unremarkable. CT scan was performed and no specific focal pathology was seen. Dr. X, pulmonologist was consulted. He also was uncertain as to the exact etiology, but viral etiology was most highly suspected. Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge. She was continued on Rocephin IV and azithromycin. Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status. She was instructed to finish azithromycin. She has two pills left at home. She is to follow up with Dr. X in two to three days. Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia. She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day). We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday. Methotrexate is known on some occasions to cause pneumonitis.
Keywords:
discharge summary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Pneumonia",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Atypical",
"pneumonia",
",",
"hypoxia",
",",
"rheumatoid",
"arthritis",
",",
"and",
"s... | [
{
"char_end": 73,
"char_start": 64,
"text": "Pneumonia",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 125,
"char_start": 107,
"text": "Atypical pneumonia",
"token_end": 21,
"token_start": 19,
"type": "problem"
},
{
"char_end": 134... | train/done_sample_2764 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Lesions - Adrenal and Pancreatic
Description: Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Both pancreatic and left adrenal lesions.
HISTORY OF PRESENT ILLNESS: This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back. He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling. He is now sleeping in an upright position. He was sent for CAT scan originally of his chest. The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion. He was subsequently was sent for a dedicated abdominal CAT scan and MRI. The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma. The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. Neoplasm could not be excluded. He was referred to us for further assessment. He denies any significant abdominal pain, any nausea or vomiting. His appetite is fine. He has had no significant changes in his bowel habits or any rectal bleeding or melena. He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps. He does have a history of frequent urination. Has been followed by urologist for this. There is no family history of pancreatic cancer. There is a history of gallstone pancreatitis in the patient's sister.
PAST MEDICAL HISTORY: Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.
ALLERGIES: ENVIRONMENTAL.
MEDICATIONS: Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.
PAST SURGICAL HISTORY: He has not had any previous surgery.
FAMILY HISTORY: His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister.
SOCIAL HISTORY: He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.
REVIEW OF SYSTEMS: He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history.
PHYSICAL EXAMINATION:
GENERAL: Presents as an obese 60-year-old white male, who appears to be in no apparent distress.
HEENT: Unremarkable.
NECK: Supple. There is no mass, adenopathy or bruit.
CHEST: Normal excursion.
LUNGS: Clear to auscultation and percussion.
COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur.
HEART: There is distant heart sounds.
ABDOMEN: Obese. It is soft. It is nontender. Examination was done as relatively sitting up as the patient was unable to recline. Bowel sounds are present. There is no obvious mass or organomegaly.
GENITALIA: Deferred.
RECTAL: Deferred.
EXTREMITIES: Revealed about 1+ pitting edema. Bilateral peripheral pulses are intact.
NEUROLOGIC: Without focal deficits. The patient is alert and oriented.
IMPRESSION: Both left adrenal and pancreatic lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy. We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention. Prior to that the patient will undergo an esophagogastroduodenoscopy.
Keywords:
general medicine, pancreatic, adrenal, lesion, ercp, esophagogastroduodenoscopy,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Lesions",
"-",
"Adrenal",
"and",
"Pancreatic",
"\n",
"Description",
":",
"Pancreatic",
"and",
"left",
"adrenal",
"lesions",
".",
"The",
"adrenal",
"lesion"... | [
{
"char_end": 95,
"char_start": 63,
"text": "Lesions - Adrenal and Pancreatic",
"token_end": 17,
"token_start": 12,
"type": "problem"
},
{
"char_end": 80,
"char_start": 73,
"text": "Adrenal",
"token_end": 15,
"token_start": 14,
"type": "bodyloc"
},
{
"char... | train/done_sample_2780 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Knee Surgery - Discharge Summary
Description: Decreased ability to perform daily living activities secondary to right knee surgery.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Decreased ability to perform daily living activities secondary to right knee surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient was transfused with 2 units of autologous blood postoperatively. She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings. The remainder of her postoperative course was uneventful. She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation. The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital. She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties. She reports having some right knee pain, which is most intense at a "certain position." The patient is unable to elaborate on which "certain position" causes her the most discomfort.
ALLERGIES: NKDA.
PAST MEDICAL HISTORY: Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.
MEDICATIONS: On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.
GENERAL: No acute distress at the time of the exam except as mentioned above complains of right knee pain at "certain position."
HEENT: Normocephalic. Sclerae nonicteric. EOMI. Dentition in good repair. Tongue is in midline with no evidence of thrush.
NECK: No thyroid enlargement. Trachea is midline.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. Normal S1 and S2.
ABDOMEN: Soft, nontender, and nondistended. No organomegaly.
EXTREMITIES: The right knee incision is intact. Steri-Strips are in place. There is some diffuse right knee edema and some limited ecchymosis as well. No calf tenderness bilaterally. Pedal pulses are palpable bilaterally.
MENTAL STATUS: The patient appears slightly anxious during the interview and exam, but she was alert and oriented.
HOSPITAL COURSE: As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation. She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery. The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours. Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain. She remarked that she had a better degree of flexibility, but she did report an increased need for pain management. Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder. On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen. The patient reported that this rash was itchy. She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively. She was treated with betamethasone cream applied to the rash b.i.d. The patient's therapy had progressed and she continued to make a good progress. At one point, the patient reported some insomnia due to right knee pain. She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain. The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range. The Coumadin was adjusted accordingly according to the INRs during her hospital course. Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally. Initial laboratory data includes a UA on 08/28/2007, which was negative. Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000. Chemistries were within normal limits. Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102. The remainder of chemistries was unremarkable. The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.
DISCHARGE DIAGNOSES:
1. Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.
2. Anxiety disorder.
3. Insomnia secondary to pain and anxiety postoperatively.
4. Postoperative constipation.
5. Contact dermatitis secondary to preoperative gardening activities.
6. Hypertension.
7. Hypothyroidism.
8. Gastroesophageal reflux disease.
9. Morton neuroma of the feet bilaterally.
10. Distant history of migraine headaches.
INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: The patient is advised to continue taking the following medications: Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily. The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926. At the present time, the patient is taking Coumadin 7 mg daily. She will remain on Coumadin for 30 days. An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary. Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office. The patient is encouraged to follow up with her primary care physician, Dr. B. As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.
Keywords:
discharge summary, decreased ability, daily living activities, knee surgery, total knee replacement, coumadin, lovenox, scd boots, ted stockings, hypertension, hypothyroidism, degenerative joint disease, gerd, anxiety disorder, morton neuroma,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Knee",
"Surgery",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Decreased",
"ability",
"to",
"perform",
"daily",
"living",
"activities",
"secondar... | [
{
"char_end": 76,
"char_start": 64,
"text": "Knee Surgery",
"token_end": 14,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 127,
"char_start": 110,
"text": "Decreased ability",
"token_end": 22,
"token_start": 20,
"type": "problem"
},
{
"char_end":... | train/done_sample_2788 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Respiratory Distress
Description: A 3-year-old abrupt onset of cough and increased work of breathing.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSES:
1. Respiratory distress.
2. Reactive airways disease.
DISCHARGE DIAGNOSES:
1. Respiratory distress.
2. Reactive airways disease.
3. Pneumonia.
HISTORY OF PRESENT ILLNESS: The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing. Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.
He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress. He also received inhaled as well as systemic corticosteroids. An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading. The patient was not started on any antibiotics and his fever resolved. However, the CRP was relatively elevated at 6.7. The CBC was normal with a white count of 9.6; however, the bands were 84%. Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.
He was taken off of continuous and he was not on room air all night. In the morning, he still had some bilateral wheezing, but no tachypnea.
DISCHARGE PHYSICAL EXAMINATION:
GENERAL: No acute distress, running around the room.
HEENT: Oropharynx moist and clear.
NECK: Supple without lymphadenopathy, thyromegaly or masses.
CHEST: Bilateral basilar wheezing. No distress.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs noted. Well perfused peripherally.
ABDOMEN: Bowel sounds present. The abdomen is soft. There is no hepatosplenomegaly, no masses. Nontender to palpation.
GENITOURINARY: Deferred.
EXTREMITIES: Warm and well perfused.
DISCHARGE INSTRUCTIONS: As follows:
1. Activity, regular.
2. Diet is regular.
3. Follow up with Dr. X in 2 days.
DISCHARGE MEDICATIONS:
1. Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.
2. QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.
3. Amoxicillin 550 mg p.o. twice daily for 10 days.
4. Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.
Total time for this discharge 37 minutes.
Keywords:
discharge summary, pneumonia, onset of cough, reactive airways disease, abrupt onset, respiratory distress, respiratory, asthma,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"Respiratory",
"Distress",
"\n",
"Description",
":",
"A",
"3",
"-",
"year",
"-",
"old",
"abrupt",
"onset",
"of",
"cough",
... | [
{
"char_end": 104,
"char_start": 84,
"text": "Respiratory Distress",
"token_end": 17,
"token_start": 15,
"type": "problem"
},
{
"char_end": 152,
"char_start": 147,
"text": "cough",
"token_end": 30,
"token_start": 29,
"type": "problem"
},
{
"char_end": 184,... | train/sample_1214 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Mesothelioma - 1
Description: Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.
(Medical Transcription Sample Report)
PRINCIPAL DIAGNOSIS: Mesothelioma.
SECONDARY DIAGNOSES: Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.
PROCEDURES
1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.
2. On August 20, 2007, thoracentesis.
3. On August 31, 2007, Port-A-Cath placement.
HISTORY AND PHYSICAL: The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion.
PAST MEDICAL HISTORY
1. Pericardectomy.
2. Pericarditis.
2. Atrial fibrillation.
4. RNCA with intracranial thrombolytic treatment.
5 PTA of MCA.
6. Mesenteric venous thrombosis.
7. Pericardial window.
8. Cholecystectomy.
9. Left thoracentesis.
FAMILY HISTORY: No family history of coronary artery disease, CVA, diabetes, CHF or MI. The patient has one family member, a sister, with history of cancer.
SOCIAL HISTORY: She is married. Employed with the US Post Office. She is a mother of three. Denies tobacco, alcohol or illicit drug use.
MEDICATIONS
1. Coumadin 1 mg daily. Last INR was on Tuesday, August 14, 2007, and her INR was 2.3.
2. Amiodarone 100 mg p.o. daily.
REVIEW OF SYSTEMS: Complete review of systems negative except as in pulmonary as noted above. The patient also reports occasional numbness and tingling of her left arm.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 123/95, heart rate 83, respirations 20, temperature 97, and oxygen saturation 97%.
GENERAL: Positive nonproductive cough and pain with coughing.
HEENT: Pupils are equal and reactive to light and accommodation. Tympanic membranes are clear.
NECK: Supple. No lymphadenopathy. No masses.
RESPIRATORY: Pleural friction rub is noted.
GI: Soft, nondistended, and nontender. Positive bowel sounds. No organomegaly.
EXTREMITIES: No edema, no clubbing, no cyanosis, no tenderness. Full range of motion. Normal pulses in all extremities.
SKIN: No breakdown or lesions. No ulcers.
NEUROLOGIC: Grossly intact. No focal deficits. Awake, alert, and oriented to person, place, and time.
LABORATORY DATA: Labs are pending.
HOSPITAL COURSE: The patient was admitted for a right-sided pleural effusion for thoracentesis on Monday by Dr. X. Her Coumadin was placed on hold. A repeat echocardiogram was checked. She was started on prophylaxis for DVT with Lovenox 40 mg subcutaneously. Her history dated back to March 2005 when she first sought medical attention for evidence of pericarditis, which was treated with pericardial window in an outside hospital, at that time she was also found to have mesenteric pain and thrombosis, is now anticoagulated. Her pericardial fluid was accumulated and she was seen by Dr. Y. At that time, she was recommended for pericardectomy, which was performed by Dr. Z. Review of her CT scan from March 2006 prior to her pericardectomy, already shows bilateral plural effusions. The patient improved clinically after the pericardectomy with resolution of her symptoms. Recently, she was readmitted to the hospital with chest pain and found to have bilateral pleural effusion, the right greater than the left. CT of the chest also revealed a large mediastinal lymph node. We reviewed the pathology obtained from the pericardectomy in March 2006, which was diagnostic of mesothelioma. At this time, chest tube placement for drainage of the fluid occurred and thoracoscopy with fluid biopsies, which were performed, which revealed epithelioid malignant mesothelioma. The patient was then stained with a PET CT, which showed extensive uptake in the chest, bilateral pleural pericardial effusions, and lymphadenopathy. She also had acidic fluid, pectoral and intramammary lymph nodes and uptake in L4 with SUV of 4. This was consistent with stage III disease. Her repeat echocardiogram showed an ejection fraction of 45% to 49%. She was transferred to Oncology service and started on chemotherapy on September 1, 2007 with cisplatin 75 mg/centimeter squared equaling 109 mg IV piggyback over 2 hours on September 1, 2007, Alimta 500 mg/ centimeter squared equaling 730 mg IV piggyback over 10 minutes. This was all initiated after a Port-A-Cath was placed. The chemotherapy was well tolerated and the patient was discharged the following day after discontinuing IV fluid and IV. Her Port-A-Cath was packed with heparin according to protocol.
DISCHARGE MEDICATIONS: Zofran, Phenergan, Coumadin, and Lovenox, and Vicodin
DISCHARGE INSTRUCTIONS: She was instructed to followup with Dr. XYZ in the office to check her INR on Tuesday. She was instructed to call if she had any other questions or concerns in the interim.
Keywords:
discharge summary, mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, deep venous thrombosis, port-a-cath placement, port a cath, iv piggyback, venous thrombosis, atrial, thrombosis, pericardial, lymphadenopathy, fluid, pericardectomy, chest, pleural,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Discharge",
"Summary",
"-",
"Mesothelioma",
"-",
"1",
"\n",
"Description",
":",
"Mesothelioma",
",",
"pleural",
"effusion",
",",
"atrial",
"fibrillation",
... | [
{
"char_end": 96,
"char_start": 84,
"text": "Mesothelioma",
"token_end": 16,
"token_start": 15,
"type": "problem"
},
{
"char_end": 126,
"char_start": 114,
"text": "Mesothelioma",
"token_end": 22,
"token_start": 21,
"type": "problem"
},
{
"char_end": 144,
... | train/sample_1262 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 1
Description: Return to work & Fit for duty evaluation.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity .
REVIEW OF SYSTEMS: Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.
MEDICATIONS: Claritin for allergic rhinitis.
ALLERGIES: None.
PHYSICAL EXAMINATION: Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft.
On examination of the shoulder, he is mild to moderately tender in the posterolateral aspect of the subacromial space. His range of motion is abduction to 90 degrees, before experiencing pain. He can push this to 120 degrees. He also has flexion of 120 degrees but it reluctant to move it past this. He has a very mild response to both Neer's and Hawkins impingement testing. He has negative sulcus, apprehension, Speed's and Yergason's testing.
DIAGNOSTIC IMAGING: Two view x-rays were taken of the shoulder. There are no osseous abnormalities or significant degenerative changes.
IMPRESSION: Right shoulder pain, most likely secondary to muscular strain. He does have a very mild evidence of impingement.
PLAN: The patient is cleared for work. He has the next three days off due to a plant shutdown. Should he have any persistent pain next week, I would considering obtaining an MRI.
Keywords:
general medicine, return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"1",
"\n",
"Description",
":",
"Return",
"to",
"work",
"&",
"Fit",
"for",
"duty",
"evaluation",
".",
"\n",
"(",
"Medical... | [
{
"char_end": 136,
"char_start": 121,
"text": "duty evaluation",
"token_end": 28,
"token_start": 26,
"type": "test"
},
{
"char_end": 307,
"char_start": 275,
"text": "new onset of right shoulder pain",
"token_end": 66,
"token_start": 60,
"type": "problem"
},
{
... | train/sample_223 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 2
Description: Initial clinic visit for foreign body in left eye.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day. He has no significant blurriness of vision or photophobia.
REVIEW OF SYSTEMS: Focal left eye pain without any changes in visual acuity or photophobia. He has no prior ophthalmologic problems. Review of systems for cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine, immunologic systems is negative.
PAST MEDICAL HISTORY: Surgeries: None. Injuries: Dislocated wrist. Illnesses: None.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: He smokes one pack of cigarettes per day. He is a social drinker. He is not married, but has two children. Hobbies: Computers, hiking, camping, fishing.
FAMILY HISTORY: Cancer, hypertension.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 132/82, respirations 12, pulse 68, temperature 98.6. Visual acuity: Bilateral 20/25, left 20/30, right 20/30.
On slit lamp examination: Lids and lacrimal apparatus normal. Anterior chambers deep and clear. Lens clear. Conjunctiva are severely injected. There is a small metallic foreign body at 6 o'clock. This is removed with the aid of the slit lamp.
DIAGNOSIS: Foreign body OS.
PLAN: Following removal of the foreign body, the patient was returned to work with the caveat that if he finds it unbearable, he can return to work and have a pressure patch placed on his eye. He will be seen for a closing visit on Month DD, YYYY.
Keywords:
general medicine, foreign body, anterior chambers, conjunctiva, lens, lids, blurriness, consult, eye, lacrimal apparatus, metallic, pain, photophobia, sensation, slit lamp examination, smokes, social drinker, visual acuity, initial clinic visit, worker, foreign, body,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Consult",
"-",
"2",
"\n",
"Description",
":",
"Initial",
"clinic",
"visit",
"for",
"foreign",
"body",
"in",
"left",
"eye",
".",
"\n",
"... | [
{
"char_end": 145,
"char_start": 121,
"text": "foreign body in left eye",
"token_end": 29,
"token_start": 24,
"type": "problem"
},
{
"char_end": 145,
"char_start": 137,
"text": "left eye",
"token_end": 29,
"token_start": 27,
"type": "bodyloc"
},
{
"char_en... | train/sample_225 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Diabetes Mellitus - SOAP Note - 1
Description: Followup diabetes mellitus, type 1.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Followup diabetes mellitus, type 1.
SUBJECTIVE: Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer.
Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has a history of gastroparesis and impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.
Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head. Was not wearing a helmet. Reports that he did not go to the emergency room and had a headache for several days after this incident. Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room. Patient did not comply. Reports that the headache has resolved. Denies any dizziness, nausea, vomiting, or other neurological abnormalities.
PHYSICAL EXAMINATION: WD, WN. Slender, 34-year-old white male. VITAL SIGNS: Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. Microalbumin 100. SKIN: There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. No signs of infection. Wound is closed with new granulation tissue. Appears to be healing well. HEENT: Normocephalic. PERRLA. EOMI. TMs pearly gray with landmarks present. Nares patent. Throat with no redness or swelling. Nontender sinuses. NECK: Supple. Full ROM. No LAD. CARDIAC: RRR. No murmurs, rubs, or gallops. RESPIRATORY: CTA. ABDOMEN: Soft, nontender. No HSM and no masses. NEURO: Significant for lower extremity numbness throughout. Microfilament test shows more than 3 regions without sensation bilaterally. Bottoms of feet appear calloused and dry. Skin is intact. There is also a small contusion on right shin which appears to be healing, less than 1/2 inch in length and 1 cm in diameter. No signs of infection at this time and appears to be healing. Cranial nerves 2-12 grossly nonfocal. Cerebellar function intact demonstrated through RAM.
ASSESSMENT:
1. Diabetes mellitus, type 1, poorly controlled.
2. Significant diabetic neuropathy with positive microalbuminuria.
3. Scalp laceration, secondary to motor vehicle accident, symptoms resolving.
4. Elevated Alk Phos, etiology unclear.
PLAN:
1. Diabetes mellitus type 1: We will follow up the elevated alkaline phosphatase with an SGGT and a hepatic function panel. The positive microalbumin is 100 today. He will be placed on a low dose Ace Inhibitor. I will put in a Prior Authorization for Lantus. I have also asked the patient to keep a log of his blood sugars for 2 weeks. Patient agrees to this. We may need to put in a referral to Endocrinology to get him stabilized. Prescription given for Prilosec OTC for GERD symptoms.
2. Followup scooter accident. Lacerations on scalp and shin appear to be healing. Discussed with patient if there are any signs of heat, swelling, infection to return to clinic. It is extremely important for him to watch these areas as he does not have feeling in the majority of his lower body.
Keywords:
general medicine, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Diabetes",
"Mellitus",
"-",
"SOAP",
"Note",
"-",
"1",
"\n",
"Description",
":",
"Followup",
"diabetes",
"mellitus",
",",
"type",
"1",
".",
"\n",
"(",
... | [
{
"char_end": 80,
"char_start": 63,
"text": "Diabetes Mellitus",
"token_end": 14,
"token_start": 12,
"type": "problem"
},
{
"char_end": 144,
"char_start": 119,
"text": "diabetes mellitus, type 1",
"token_end": 28,
"token_start": 23,
"type": "problem"
},
{
... | train/sample_227 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Toothache - ER Visit
Description: Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Toothache.
HISTORY OF PRESENT ILLNESS: This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.
REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. No fatigue or weakness. No recent weight change. HEENT: No headache, no neck pain, the toothache pain for the past three days as previously mentioned. There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. The patient denies any rhinorrhea. No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No focal weakness or numbness. Normal speech. HEMATOLOGIC/LYMPHATIC: No lymph node swelling has been noted.
PAST MEDICAL HISTORY: Chronic knee pain.
CURRENT MEDICATIONS: OxyContin and Vicodin.
ALLERGIES: PENICILLIN AND CODEINE.
SOCIAL HISTORY: The patient is still a smoker.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient is a little overweight but otherwise appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Eyes are normal with clear conjunctiva and cornea bilaterally. There is no icterus, injection, or discharge. Pupils are 3 mm and equally round and reactive to light bilaterally. There is no absence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Ears are normal bilaterally without any sign of infection. There is no erythema, swelling of canals. Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. Nose is normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. NECK: Supple, nontender, and full range of motion. There is no meningismus. No cervical lymphadenopathy. No JVD. Mouth and oropharynx shows multiple denture and multiple dental caries. The patient has tenderness to tooth #12 as well as tooth #21. The patient has normal gums. There is no erythema or swelling. There is no purulent or other discharge noted. There is no fluctuance or suggestion of abscess. There are no new dental fractures. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion or swelling. The buccal membranes are normal. Mucous membranes are moist. The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally without shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to back, arms and legs. The patient has normal use of his extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact to the extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No cervical lymphadenopathy is palpated.
EMERGENCY DEPARTMENT COURSE: The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.
DIAGNOSES:
1. ODONTALGIA.
2. MULTIPLE DENTAL CARIES.
CONDITION UPON DISPOSITION: Stable.
DISPOSITION: To home.
PLAN: The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. The patient was requested to have reevaluation within two days. The patient was given a prescription for Percocet and clindamycin. The patient was given drug precautions for the use of these medicines. The patient was offered discharge instructions on toothache but states that he already has it. He declined the instructions. The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.
Keywords:
general medicine, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Toothache",
"-",
"ER",
"Visit",
"\n",
"Description",
":",
"Patient",
"has",
"had",
"multiple",
"problems",
"with",
"his",
"teeth",
"due",
"to",
"extensiv... | [
{
"char_end": 72,
"char_start": 63,
"text": "Toothache",
"token_end": 13,
"token_start": 12,
"type": "problem"
},
{
"char_end": 145,
"char_start": 113,
"text": "multiple problems with his teeth",
"token_end": 27,
"token_start": 22,
"type": "problem"
},
{
"... | train/sample_2751 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: ORIF - Discharge Summary
Description: Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS: Right tibial plateau fracture.
DISCHARGE DIAGNOSES: Right tibial plateau fracture and also medial meniscus tear on the right side.
PROCEDURES PERFORMED: Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.
CONSULTATIONS: To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.
HOSPITAL COURSE: The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence. The patient seemed to be recovering well. The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload. The patient was given nebulizer treatment and Lasix increased the same to resolve the problem. The patient was comfortable, stabilized, breathing well. On day #12, was transferred to ABCD.
DISCHARGE INSTRUCTIONS: The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.
DIET: Regular.
ACTIVITY AND LIMITATIONS: Nonweightbearing to the right lower extremity. The patient is to continue CPM machine while in bed along with antiembolic stockings. The patient will require nursing, physical therapy, occupational therapy, and social work consults.
DISCHARGE MEDICATIONS: Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.
FOLLOWUP: Follow up with Dr. Y in 7 to 10 days in office.
CONDITION ON DISCHARGE: Stable.
Keywords:
discharge summary, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"ORIF",
"-",
"Discharge",
"Summary",
"\n",
"Description",
":",
"Open",
"reduction",
"and",
"internal",
"fixation",
"(",
"ORIF",
")",
"of",
"right",
"Scha... | [
{
"char_end": 68,
"char_start": 64,
"text": "ORIF",
"token_end": 13,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 145,
"char_start": 102,
"text": "Open reduction and internal fixation (ORIF)",
"token_end": 27,
"token_start": 19,
"type": "treatment"
},... | train/sample_2760 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Hip Surgery - Discharge Summar
Description: Decreased ability to perform daily living activity secondary to recent right hip surgery.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Decreased ability to perform daily living activity secondary to recent right hip surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively. She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services. Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0. She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery. Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.
MEDICATIONS: Medications taken at home are Paxil, MOBIC, and Klonopin.
MEDICATIONS ON TRANSFER: Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker.
REVIEW OF SYSTEMS: As mentioned above. She has a history of migraine headaches associated with her menstrual cycle. She wears glasses and has a history of floaters. She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign. The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis. She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery. She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties. First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.
PHYSICAL EXAMINATION:
VITAL SIGNS: At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.
GENERAL: No acute distress at the time of exam.
HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Dentition is in good repair.
NECK: Trachea is at the midline.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Bowel sounds are heard throughout. Soft and nontender.
EXTREMITIES: Right hip incision is clean, intact, and no drainage is noted. There is diffuse edema, which extends distally. There is no calf tenderness per se bilaterally and Homans sign is negative. There is no pedal edema.
MENTAL STATUS: Alert and oriented x3, pleasant and cooperative during the exam.
LABORATORY DATA: Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6. The BUN was normal at 8, creatinine was 0.9, INR was 1.49. CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.
IMPRESSION:
1. Status post right total hip replacement. The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.
2. Postoperative anemia, Feosol 325 mg one q.d.
3. Pain management. Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain. Additionally, she will utilize ice to help decrease edema.
4. Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.
5. Osteoarthritis, Celebrex 200 mg b.i.d.
6. GI prophylaxis, Protonix 40 mg b.i.d. Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.
7. DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR. She will continue on 5 mg every day.
8. Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis. Monitor for any possibility of DVT.
Keywords:
discharge summary, decreased ability, hip surgery, hip replacement, physical therapy, occupational therapy,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Hip",
"Surgery",
"-",
"Discharge",
"Summar",
"\n",
"Description",
":",
"Decreased",
"ability",
"to",
"perform",
"daily",
"living",
"activity",
"secondary",
... | [
{
"char_end": 75,
"char_start": 64,
"text": "Hip Surgery",
"token_end": 14,
"token_start": 12,
"type": "treatment"
},
{
"char_end": 125,
"char_start": 108,
"text": "Decreased ability",
"token_end": 22,
"token_start": 20,
"type": "problem"
},
{
"char_end": ... | train/sample_2789 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 1
Description: Sample female physical exam
(Medical Transcription Sample Report)
FEMALE PHYSICAL EXAMINATION
Eye: Eyelids normal color, no edema. Conjunctivae with no erythema, foreign body, or lacerations. Sclerae normal white color, no jaundice. Cornea clear without lesions. Pupils equally responsive to light. Iris normal color, no lesions. Anterior chamber clear. Lacrimal ducts normal. Fundi clear.
Ear: External ear has no erythema, edema, or lesions. Ear canal unobstructed without edema, discharge, or lesions. Tympanic membranes clear with normal light reflex. No middle ear effusions.
Nose: External nose symmetrical. No skin lesions. Nares open and free of lesions. Turbinates normal color, size and shape. Mucus clear. No internal lesions.
Throat: No erythema or exudates. Buccal mucosa clear. Lips normal color without lesions. Tongue normal shape and color without lesion. Hard and soft palate normal color without lesions. Teeth show no remarkable features. No adenopathy. Tonsils normal shape and size. Uvula normal shape and color.
Neck: Skin has no lesions. Neck symmetrical. No adenopathy, thyromegaly, or masses. Normal range of motion, nontender. Trachea midline.
Chest: Symmetrical. Clear to auscultation bilaterally. No wheezing, rales or rhonchi. Chest nontender. Normal lung excursion. No accessory muscle use.
Cardiovascular: Heart has regular rate and rhythm with no S3 or S4. Heart rate is normal.
Abdominal: Soft, nontender, nondistended, bowel sounds present. No hepatomegaly, splenomegaly, masses, or bruits.
Genital: Labia majora normal shape without erythema or lesions. Labia minora normal shape without erythema or lesions. Clitoris normal shape and contour. Vaginal mucosa normal color without lesions. No significant discharge. Cervix normal shape and parity without lesions. Ovaries normal shape and contour. No pelvic masses. Uterus normal shape and contour. No external hemorrhoids.
Musculoskeletal: Normal strength all muscle groups. Normal range of motion all joints. No joint effusions. Joints normal shape and contour. No muscle masses.
Foot: No erythema. No edema. Normal range of motion all joints in the foot. Nontender. No pain with inversion, eversion, plantar or dorsiflexion.
Ankle: Anterior and posterior drawer test negative. No pain with inversion, eversion, dorsiflexion, or plantar flexion. Collateral ligaments intact. No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.
Knee: Normal range of motion. No joint effusion, erythema, nontender. Anterior and posterior drawer tests negative. Lachman's test negative. Collateral ligaments intact. Bursas nontender without edema.
Wrist: Normal range of motion. No edema or effusion, nontender. Negative Tinel and Phalen tests. Normal strength all muscle groups.
Elbow: Normal range of motion. No joint effusion or erythema. Normal strength all muscle groups. Nontender. Olecranon bursa flat and nontender, no edema. Normal supination and pronation of forearm. No crepitus.
Hip: Negative swinging test. Trochanteric bursa nontender. Normal range of motion. Normal strength all muscle groups. No pain with eversion and inversion. No crepitus. Normal gait.
Psychiatric: Alert and oriented times four. No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality. Affect is appropriate. No psychomotor slowing or agitation. Eye contact is appropriate.
Keywords:
general medicine, physical examination, abdominal, anterior chamber, cardiovascular, chest, ear, ear canal, eye, eyelids, female, female physical examination, labia majora, labia minora, nares, neck symmetrical, vaginal mucosa, crepitus, ecchymosis, edema, erythema, joint effusion, normal range of motion, shape and contour, normal strength, joint effusions, normal color, nontender, lesions, effusions, muscle, joints,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Female",
"Physical",
"Exam",
"-",
"1",
"\n",
"Description",
":",
"Sample",
"female",
"physical",
"exam",
"\n",
"(",
"Medical",
"Transcription",
"Sample",
... | [
{
"char_end": 83,
"char_start": 63,
"text": "Female Physical Exam",
"token_end": 15,
"token_start": 12,
"type": "test"
},
{
"char_end": 128,
"char_start": 108,
"text": "female physical exam",
"token_end": 24,
"token_start": 21,
"type": "test"
},
{
"char_en... | train/sample_324 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 6
Description: Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same.
CURRENT MEDICATIONS: Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.
ALLERGIES: Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.
OBJECTIVE:
General: He is a well-developed, well-nourished, elderly male in no acute distress.
Vital Signs: His age is 66. Temperature: 97.7. Blood pressure: 134/80. Pulse: 88. Weight: 201 pounds.
HEENT: Head was normocephalic. Examination of the throat reveals it to be clear. He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.
Neck: Supple without adenopathy or thyromegaly.
Lungs: Clear.
Heart: Regular rate and rhythm.
Extremities: He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder. Back has limited range of motion. He is nontender to his back. Deep tendon reflexes are 2+ bilaterally in lower extremities. Straight leg raising is positive for back pain on the right side at 90 degrees.
Abdomen: Soft, nontender without hepatosplenomegaly or mass. He has normal bowel sounds.
ASSESSMENT:
1. Clostridium difficile enteritis, improved.
2. Right shoulder pain.
3. Chronic low back pain.
4. Yeast thrush.
5. Coronary artery disease.
6. Urinary retention, which is doing better.
PLAN: I put him on Diflucan 200 mg daily for seven days. We will have him stop his metronidazole little earlier at his request. He can drop it down to t.i.d. until Friday of this week and then finish Fridays dose and then stop the metronidazole and that will be more than a 10-day course. I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.) Recheck with me in two to three weeks.
Keywords:
general medicine, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"SOAP",
"-",
"6",
"\n",
"Description",
":",
"Patient",
"with",
"several",
"medical",
"problems",
"-",
"mouth",
"being",
"sore",
",",
"coug... | [
{
"char_end": 130,
"char_start": 106,
"text": "several medical problems",
"token_end": 25,
"token_start": 22,
"type": "problem"
},
{
"char_end": 149,
"char_start": 133,
"text": "mouth being sore",
"token_end": 29,
"token_start": 26,
"type": "problem"
},
{
... | train/sample_367 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 10
Description: Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: The patient is here for two-month followup.
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she bends over then stands up quickly. She has had no nausea, vomiting, or diarrhea. She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year. The patient is wanting to lose weight before her surgery. She is concerned about possible coronary disease or stroke risk. She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable. She has had fairly normal lipid panel, last being checked on 11/26/2003. Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129. The patient is a nonsmoker. Her fasting glucose in November 2003 was within normal limits at 94. Her fasting insulin level was normal. Repeat nonfasting glucose was 109 on 06/22/2004. She does not have history of diabetes. She does not exercise regularly and is not able to because of knee pain. She also has had difficulties with low back pain. X-ray of the low back did show a mild compression fracture of L1. She has had no falls that would contribute to a compression fracture. She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan. She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.
CURRENT MEDICATIONS: Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.
ALLERGIES: Bactrim, which causes nausea and vomiting, and adhesive tape.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Depression.
3. Myofascitis of the feet.
4. Severe osteoarthritis of the knee.
5. Removal of the melanoma from the right thigh in 1984.
6. Breast biopsy in January of 1997, which was benign.
7. History of Holter monitor showing ectopic beat. Echocardiogram was normal. These were in 1998.
8. Compression fracture of L1, unknown cause. She had had no injury. Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.
SOCIAL HISTORY: The patient is married. She is a nonsmoker and nondrinker.
REVIEW OF SYSTEMS: As per the HPI.
PHYSICAL EXAMINATION:
General: This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.
Vital signs: Weight: Refused. Blood pressure: 148/82, on recheck by myself with a large cuff, it was 125/60. Pulse: 64. Respirations: 20. Temperature: 96.3.
Neck: Supple. Carotids are silent.
Chest: Clear to auscultation.
Cardiovascular: Revealed a regular rate and rhythm without murmur, S3, or S4.
Extremities: Revealed no edema.
Neurologic: Grossly intact.
RADIOLOGY: EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.
ASSESSMENT:
1. Hypertension, well controlled.
2. Family history of cerebrovascular accident.
3. Compression fracture of L1, mild.
4. Osteoarthritis of the knee.
5. Mildly abnormal chest x-ray.
PLAN:
1. We will get a C-reactive protein cardiac.
2. We discussed weight loss options. I would recommend Weight Watchers or possibly having her see a dietician. She will think about these options. She is not able to exercise regularly right now because of knee pain.
3. We would recommend a screening colonoscopy. She states that we discussed this in the past and she canceled her appointment to have that done. She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.
4. We will start Fosamax 70 mg once weekly. She is to take this in the morning on an empty stomach with full glass of water. She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.
5. I would like to see her back in one to two months. At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing. One would also consider preoperative beta-blocker for cardiac protection.
Keywords:
general medicine, progress note, followup, hypertension, chest pain, lightheadedness, shortness of breath, osteoporosis, cerebrovascular accident, compression fracture, chest x-ray, osteoarthritis of the knee, dexa scan, dexa, osteoarthritis, cardiac, compression, knee,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Progress",
"Note",
"-",
"10",
"\n",
"Description",
":",
"Patient",
"comes",
"in",
"for",
"two",
"-",
"month",
"followup",
"-",
"Hypertens... | [
{
"char_end": 157,
"char_start": 145,
"text": "Hypertension",
"token_end": 31,
"token_start": 30,
"type": "problem"
},
{
"char_end": 180,
"char_start": 177,
"text": "CVA",
"token_end": 36,
"token_start": 35,
"type": "problem"
},
{
"char_end": 208,
"cha... | train/sample_380 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 1
Description: Sample progress note - Gen Med.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Followup on diabetes mellitus, status post cerebrovascular accident.
SUBJECTIVE: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.
MEDICATIONS: Refer to chart.
ALLERGIES: Refer to chart.
PHYSICAL EXAMINATION:
Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.
General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition.
Skin: Dry and flaky.
CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right.
Lungs: Diminished but clear.
Abdomen: Scaphoid.
Rectal: His prostate check was normal per Dr. Gill.
Neuro: Sensation with monofilament testing is better on the left than it is on the right.
IMPRESSION:
1. Diabetes mellitus.
2. Neuropathy.
3. Status post cerebrovascular accident.
PLAN: Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.
Keywords:
general medicine, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Progress",
"Note",
"-",
"1",
"\n",
"Description",
":",
"Sample",
"progress",
"note",
"-",
"Gen",
"Med",
".",
"\n",
"(",
"Medical",
"Tra... | [
{
"char_end": 218,
"char_start": 201,
"text": "diabetes mellitus",
"token_end": 43,
"token_start": 41,
"type": "problem"
},
{
"char_end": 256,
"char_start": 232,
"text": "cerebrovascular accident",
"token_end": 48,
"token_start": 46,
"type": "problem"
},
{
... | train/sample_68 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 3
Description: Sample progress note - Gen Med.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis.
SUBJECTIVE: A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly.
PAST MEDICAL HISTORY: Refer to chart.
MEDICATIONS: Refer to chart.
ALLERGIES: Refer to chart.
PHYSICAL EXAMINATION:
Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.
General: A 70-year-old female who does not appear to be in acute distress.
HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull.
Neck: Supple.
Heart: Clear.
Lungs: Clear.
Abdomen: Large, nontender. No swelling.
IMPRESSION:
1. Hypercholesterolemia.
2. Diabetes mellitus.
3. Sinusitis.
PLAN:
1. Allegra D 1 p.o. b.i.d. x 3 days.
2. Allegra 180 mg daily x 7 days.
3. Check an A1c, BMP, lipid profile, TSH.
4. She was given a copy of Partners in Prevention.
5. We discussed colonoscopy, and she is not ready to do that right now.
6. Will check stools for occult blood x 3. She is aware that a colonoscopy could pick up an early cancer.
7. Diet, exercise, weight loss stressed. We will let her know the results of her tests.
8. Refilled her prescriptions x 6 months.
Keywords:
general medicine, diabetes mellitus, accu-cheks, sinusitis, abdominal pain, constipation, diarrhea, hypercholesterolemia, nausea, progress note, vomiting, weight loss, colonoscopy, diabetes,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"General",
"Medicine",
"\n",
"Sample",
"Name",
":",
"Gen",
"Med",
"Progress",
"Note",
"-",
"3",
"\n",
"Description",
":",
"Sample",
"progress",
"note",
"-",
"Gen",
"Med",
".",
"\n",
"(",
"Medical",
"Tra... | [
{
"char_end": 218,
"char_start": 201,
"text": "diabetes mellitus",
"token_end": 43,
"token_start": 41,
"type": "problem"
},
{
"char_end": 240,
"char_start": 220,
"text": "hypercholesterolemia",
"token_end": 45,
"token_start": 44,
"type": "problem"
},
{
"ch... | train/sample_71 |
Sample Type / Medical Specialty: Discharge Summary
Sample Name: Psychiatric Discharge Summary - 2
Description: Discharge summary of a patient with depression and high risk behavior.
(Medical Transcription Sample Report)
DISCHARGE SUMMARY
SUMMARY OF TREATMENT PLANNING: This discharge is at the family's request.
IDENTIFIED PROBLEMS/OUTCOMES:
1. Depression.
2. High risk behavior.
The patient easily was very depressed and anxious with paranoia. The patient has improved, but is at high risk for relapse. She needs RTC level of care.
INTERVENTIONS: A developmentally appropriate, group-oriented therapy program was the primary treatment modality. The attending psychiatrist provided evaluation for and management of psychotropic medications. The clinical therapist facilitated individual, group, and family therapy.
COURSE IN HOSPITAL: The patient was in the hospital from 06/11/04 until 07/13/04. The most prominent symptoms and behaviors while the patient was here were the following: Perceptual disturbances, disorganized thoughts, she was suspicious at times, at some point she was complaining of audiovisual hallucinations. She was quiet showing a flat affect, irritable, anxious and depressed moods, tearful at times, homesick, limited interaction with peers. She was attending groups, however, was showing limited participation. She was superficial, not really working too much on her issues, more focused on how soon she was going to be discharged more than working on her issues. She stated "strange feelings and sensations". The patient has shown some improvement in general. However, she is not completely stable yet, and she sometimes is of relapse. She is probably just waiting for the discharge to the next level of care, which is the RTC program. However, the patient's family will not follow our recommendations in this respect at this point.
DIAGNOSTIC AND THERAPEUTIC TEST/EVALUATIONS: A sleep-deprived EEG was done and was normal. EKG was also done and it seems to be grossly normal as well.
CONSULTATIONS: The patient was seen by one of our medical consultants for H&P for clearance to continue psychiatric treatment. Basic blood work was done including basic metabolic panel, CBC, TSH, UA, and urine drug screen. Per our medical consultant, thyroid dysfunction by history, however, thyroid panel, T3, T4, and TSH results are within normal limits. History of asthma, by history, and also history of heart murmur (not heard during H&P exam). CBC: Hematocrit of 35.5, low; absolute monocytes of 0.5, high; otherwise essentially normal lab results.
FINAL DIAGNOSIS:
AXIS I: Major depression, recurrent, with psychotic features.
AXIS II: Deferred.
AXIS III: No acute major medical conditions.
AXIS IV: Psychosocial stressors.
AXIS V: GAF: 50 to 60, current.
CONDITIONS ON DISCHARGE: The patient is alert, oriented to time, place, person, and situation. She denies suicidal or homicidal ideas at present exploration. She denies perception disturbances. She does not seem to be responding to internal stimuli at this point. She verbally contracted for safety.
PROGNOSIS: Guarded.
DISCHARGE PLAN: The patient will be discharged per family's request. She will continue treatment at hospital. The intake appointment will be on 07/21/04 at 2:00 p.m.
NOTE: Treatment team recommendation for the patient is RTC (Residential Treatment Center) program. However, legal guardian will not follow our recommendations at this point.
DISCHARGE INSTRUCTIONS: The patient should visit her family doctor, cardiologist, and OB/GYN doctor for regular annual checkups. She should visit all of these doctors in regard to her lab results and/or her physical (medical conditions). Please see under consultations.
DISCHARGE MEDICATION: Seroquel 25 mg p.o. a.m. #30 pills no refills; Seroquel 50 mg p.o. q.h.s; Benadryl 50 mg p.o. q. 6h p.r.n. for anxiety or agitation #30 pills; Wellbutrin XL 300 mg p.o. q.a.m.; vitamin E 400 IU p.o. q.d. #30 pills; Restoril 25 mg p.o. p.r.n. for anxiety #16 pills.
Note: Watch for the possibility of galactorrhea. Of note: The patient had galactorrhea (lactation) as a side effect from the use of Risperdal. Do not give Risperdal.
The patient and patient's legal guardian were well oriented by me, the therapist in charge, and nursing staff.
Keywords:
discharge summary, psychiatric, depression, gaf, high risk behavior, psychosocial stressors, rtc, residential treatment center, anxious, paranoia, psychiatric treatment, psychotropic medications, sleep-deprived eeg, legal guardian, discharge, oriented, axis,
| [
"Sample",
"Type",
"/",
"Medical",
"Specialty",
":",
"Discharge",
"Summary",
"\n",
"Sample",
"Name",
":",
"Psychiatric",
"Discharge",
"Summary",
"-",
"2",
"\n",
"Description",
":",
"Discharge",
"summary",
"of",
"a",
"patient",
"with",
"depression",
"and",
"high... | [
{
"char_end": 157,
"char_start": 147,
"text": "depression",
"token_end": 27,
"token_start": 26,
"type": "problem"
},
{
"char_end": 180,
"char_start": 162,
"text": "high risk behavior",
"token_end": 31,
"token_start": 28,
"type": "problem"
},
{
"char_end": ... | train/sample_86 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.