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Sample Type / Medical Specialty: General Medicine
Sample Name: Disseminated Intravascular Coagulation
Description: Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.
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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.
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Death Summary - 1
Description: Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Post Thyroidectomy - Discharge Summary
Description: Symptomatic thyroid goiter. Total thyroidectomy.
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ADMISSION DIAGNOSIS: Symptomatic thyroid goiter.
DISCHARGE DIAGNOSIS: Symptomatic thyroid goiter.
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Sample Type / Medical Specialty: General Medicine
Sample Name: Anemia - Consult
Description: Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.
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Sample Type/Medical Specialty :
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Sample Name : Normal
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Neonatal Discharge Summary - 1
Description: Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.
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Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Female ROS Template
Description: Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Neck Pain - Discharge Summary
Description: Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
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Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 4
Description: An example/template for a routine normal male physical exam.
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Sample Type / Medical Specialty: General Medicine
Sample Name: Air Under Diaphragm - Consult
Description: Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.
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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 under... | [
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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.
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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.
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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.
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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.
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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.
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Sample Type/Medical Specialty : General Medicine
Sample Name : Gen Med Consult - 49
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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.
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Sample Type/Medical Specialty : General Medicine
Sample Name : Nausea & Vomiting
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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.
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Sample Type/Medical Specialty :
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Sample Name : Normal Female Exam Template
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: Discharge Summary
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty : General Medicine Sample Name : Gen Med Consult - 33
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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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 im... | [
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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
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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Sample Type / Medical Specialty: General Medicine
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"text": "left eye",
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"type": "bodyloc"
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Sample Type / Medical Specialty: General Medicine
Sample Name: Diabetes Mellitus - SOAP Note - 1
Description: Followup diabetes mellitus, type 1.
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CHIEF COMPLAINT: Followup diabetes mellitus, type 1.
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... | train/sample_227 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Toothache - ER Visit
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"... | 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.
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ADMISSION DIAGNOSIS: Right tibial plateau fracture.
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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.
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CHIEF COMPLAINT: Decreased ability to perform daily living activity secondary to rec... | [
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"char_end": ... | train/sample_2789 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 1
Description: Sample female physical exam
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FEMALE PHYSICAL EXAMINATION
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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
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SUBJECTIVE: The patient is in with several medical problems. He complains his mouth being... | [
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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.
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"cha... | train/sample_380 |
Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 1
Description: Sample progress note - Gen Med.
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CHIEF COMPLAINT: Followup on diabetes mellitus, status post cerebrovascular accident.
SUBJECTIVE: This is a 70-year-old male who has no particular c... | [
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... | 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 diabete... | [
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{
"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.
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{
"char_end": ... | train/sample_86 |
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