transcription stringlengths 11 18.4k | medical_specialty int64 0 39 |
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cc:, right shoulder pain.,hx: ,this 46 y/o rhf presented with a 4 month history of right neck and shoulder stiffness and pain. the symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and rue pain. the late... | 22 |
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, subseq... | 5 |
chief complaint:, jaw pain this morning.,brief history of present illness:, this is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out mi and coronary artery disease. the patient has history of hypercholesterolemia, presently on lipitor 20 mg a day and hyperthyroid... | 15 |
preoperative diagnosis:, blocked ventriculoperitoneal shunt.,postoperative diagnosis:, blocked ventriculoperitoneal shunt.,procedure: , ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,anesthesia: , general.,history: , the patient is nonverbal. he is almost... | 23 |
preoperative diagnosis:, bunion, right foot.,postoperative diagnosis:, bunion, right foot.,procedure performed:, austin/akin bunionectomy, right foot.,history: , this 77-year-old african-american female presents to abcd general hospital with the above chief complaint. the patient states she has had a bunion deformi... | 27 |
exam: , carotid and cerebral arteriograms.,indication: , abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,impression:,1. complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. mild stenosis of the right internal carotid artery measu... | 3 |
preoperative diagnosis: , hemangioma, nasal tip.,postoperative diagnosis:, hemangioma, nasal tip.,procedure performed: ,1. debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2. rhinoplasty.,estimated blood loss: ,minimal.,findings: , large hemangioma involving the midline of the columel... | 38 |
preoperative diagnosis:,1. cholelithiasis.,2. chronic cholecystitis.,postoperative diagnosis:,1. cholelithiasis.,2. chronic cholecystitis.,name of operation: , laparoscopic cholecystectomy.,anesthesia:, general.,findings:, the gallbladder was thickened and showed evidence of chronic cholecystitis. there was a gr... | 14 |
allowed condition: , right shoulder sprain and right rotator cuff tear (partial).,contested condition:, ac joint arthrosis right aggravation.,disallowed condition: , | 18 |
preoperative diagnosis: , coronary occlusive disease.,postoperative diagnosis: , coronary occlusive disease.,operation procedure: , coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. total car... | 38 |
history of present illness: , the patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. the patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion def... | 27 |
preoperative diagnosis: , right carpal tunnel syndrome.,postoperative diagnosis:, right carpal tunnel syndrome.,procedure performed: , right carpal tunnel release.,procedure note: ,the right upper extremity was prepped and draped in the usual fashion. iv sedation was supplied by the anesthesiologist. a local block ... | 38 |
diagnosis on admission: , gastrointestinal bleed.,diagnoses on discharge,1. gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. atherosclerotic cardiovascular disease.,3. hypothyroidism.,procedure:, colonoscopy.,findings:, poor prep with friable internal hemorrhoids, but no gross... | 14 |
preoperative diagnosis:, rotator cuff tear, right shoulder.,postoperative diagnoses:,1. massive rotator cuff tear, right shoulder.,2. near complete biceps tendon tear, right shoulder.,3. chondromalacia of glenohumeral joint, right shoulder.,4. glenoid labrum tear, right shoulder.,procedure performed: ,1. arthros... | 27 |
because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay. children begin to speak some words by 18 months. children with fluid in both ears can show significant delay in their use of language. in addition, young children learn to pronounce words by hearing t... | 11 |
adenoidectomy,procedure:, the patient was brought into the operating room suite, anesthesia administered via endotracheal tube. following this the patient was draped in standard fashion. the crowe-davis mouth gag was inserted in the oral cavity. the palate and tonsils were inspected, the palate was suspended with a... | 11 |
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. the... | 15 |
preoperative diagnoses:,1. nasal septal deviation.,2. bilateral internal nasal valve collapse.,3. bilateral external nasal valve collapse.,postoperative diagnoses:,1. nasal septal deviation.,2. bilateral internal nasal valve collapse.,3. bilateral external nasal valve collapse.,procedures:,1. revision septoplast... | 11 |
the patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation. vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,the olympus single-channel endoscope was passed under direct ... | 38 |
preoperative diagnoses: , bilateral chronic otitis media,postoperative diagnoses:, bilateral chronic otitis media,anesthesia:, general mask,name of operation:, bilateral myringotomy with placement of pe tubes,procedure:, the patient was taken to the operating room and placed in the supine position. after adequate ... | 11 |
identifying data: , the patient is a 41-year-old african-american male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,chief compliant: , "i'm here because i'm different." the patient exhibits poor insight into illness and need for tr... | 32 |
the patient states that she has been doing fairly well at home. she balances her own checkbook. she does not do her own taxes, but she has never done so in the past. she states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. she denies burning any dishes becau... | 22 |
cause of death:,1. acute respiratory failure.,2. chronic obstructive pulmonary disease exacerbation.,secondary diagnoses:,1. acute respiratory failure, probably worsened by aspiration.,2. acute on chronic renal failure.,3. non-q wave myocardial infarction.,4. bilateral lung masses.,5. occlusive carotid disease.,... | 10 |
preoperative diagnosis: , metastatic papillary cancer, left neck.,postoperative diagnosis: , metastatic papillary cancer, left neck.,operation performed: , left neck dissection.,anesthesia: ,general endotracheal.,indications: , the patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, remo... | 11 |
preoperative diagnosis:, protein-calorie malnutrition.,postoperative diagnosis: , protein-calorie malnutrition.,procedure performed:, percutaneous endoscopic gastrostomy (peg) tube.,anesthesia: , conscious sedation per anesthesia.,specimen: , none.,complications: , none.,history: ,the patient is a 73-year-old male wh... | 14 |
xyz, m.d. ,suite 123, abc avenue ,city, state 12345 ,re: xxxx, xxxx ,mr#: 0000000,dear dr. xyz: ,xxxx was seen in followup in the pediatric urology clinic. i appreciate you speaking with me while he was in clinic. he continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of ... | 29 |
identification: , the patient is a 15-year-old female.,chief complaint: , right ankle pain.,history of present illness:, the patient was running and twisted her right ankle. there were no other injuries. she complains of right ankle pain on the lateral aspect. she is brought in by her mother. her primary care phys... | 5 |
preoperative diagnosis:, severe degenerative joint disease of the right knee.,postoperative diagnosis: , severe degenerative joint disease of the right knee.,procedure:, right total knee arthroplasty using a biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm maxim tibial component, ... | 27 |
chief complaint:, chronic abdominal pain.,history of present illness:, 23-year-old hispanic male who presented for evaluation of chronic abdominal pain. patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. there are also occasional episodes of stabbing e... | 5 |
procedures performed:,1. left heart catheterization.,2. bilateral selective coronary angiography.,3. left ventriculogram was not performed.,indication: , non-st elevation mi.,procedure: , after risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consen... | 38 |
history: , the patient is a 48-year-old female who was seen in consultation requested from dr. x on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. the patient reports she has been having daily headaches since 02/25/2008. she has been getting pulsations in the head with heartbeat sounds. headaches are... | 11 |
indication: , rectal bleeding.,premedication:, see procedure nurse ncs form.,procedure: , | 38 |
preoperative diagnosis:, metastatic glossal carcinoma, needing chemotherapy and a port.,postoperative diagnosis: , metastatic glossal carcinoma, needing chemotherapy and a port.,procedures,1. open exploration of the left subclavian/axillary vein.,2. insertion of a double lumen port through the left femoral vein, rad... | 3 |
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 du... | 13 |
preoperative diagnosis: ,left hemothorax, rule out empyema.,postoperative diagnosis: , left hemothorax rule out empyema.,procedure: , insertion of a 12-french pigtail catheter in the left pleural space.,procedure detail: ,after obtaining informed consent, the patient was taken to the minor or in the same day surgery ... | 38 |
exam:, ct head.,reason for exam:, seizure disorder.,technique:, noncontrast ct head.,findings: , there is no evidence of an acute intracranial hemorrhage or infarction. there is no midline shift, intracranial mass, or mass effect. there is no extra-axial fluid collection or hydrocephalus. visualized portions of t... | 33 |
preoperative diagnosis: , right inguinal hernia. ,postoperative diagnosis:, right direct inguinal hernia. ,procedure:, right direct inguinal hernia repair with phs mesh system. ,anesthesia:, general with endotracheal intubation. ,procedure in detail: , the patient was taken to the operating room and placed supine on... | 38 |
preoperative diagnosis: , recurrent right inguinal hernia, as well as phimosis.,postoperative diagnosis:, recurrent right inguinal hernia, as well as phimosis.,procedure performed: , laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,anesthesia: , general endotracheal.,complications: , non... | 39 |
subjective:, the patient is a 68-year-old white female who presents for complete physical, pap and breast exam. her last pap smear was 05/02/2002. her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest. has awakened her at night on ... | 24 |
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 da... | 35 |
preoperative diagnoses:,1. acute on chronic renal failure.,2. uremia.,postoperative diagnoses:,1. acute on chronic renal failure.,2. uremia.,procedure performed: ,insertion of a right internal jugular vein hemodialysis catheter.,anesthesia: , 1% local lidocaine.,blood loss: , less than 5 cc.,complications: , none.... | 21 |
preoperative diagnoses:,1. status post multiple trauma/motor vehicle accident.,2. acute respiratory failure.,3. acute respiratory distress/ventilator asynchrony.,4. hypoxemia.,5. complete atelectasis of left lung.,postoperative diagnoses:,1. status post multiple trauma/motor vehicle accident.,2. acute respirator... | 38 |
preoperative diagnosis: , coronary artery disease.,postoperative diagnosis: , coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,description of procedure:,left heart catheterization with angiography and mid abdominal aortography:,under local anesthesia with 2% li... | 38 |
preoperative diagnosis:, refractory priapism.,postoperative diagnosis:, refractory priapism.,procedure performed: , cavernosaphenous shunt.,anesthesia:, general.,estimated blood loss: ,400 cc.,fluids: , iv fluids 1600 crystalloids, one liter packed red blood cells.,indications for procedure: ,this is a 34-year-old... | 39 |
procedure performed: , inguinal herniorrhaphy.,procedure: , after informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. general endotracheal anesthesia was induced without incident. the patient was prepped and draped in the usual sterile manner.,a stan... | 39 |
cc: ,low back pain (lbp) with associated ble weakness.,hx:, this 75y/o rhm presented with a 10 day h/o progressively worsening lbp. the lbp started on 12/3/95; began radiating down the rle, on 12/6/95; then down the lle, on 12/9/95. by 12/10/95, he found it difficult to walk. on 12/11/95, he drove himself to his local ... | 33 |
preoperative diagnoses:, hypertrophy of tonsils and adenoids, and also foreign body of right ear.,postoperative diagnoses:, hypertrophy of tonsils and adenoids, and also foreign body of right ear.,operations:, tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,anesthesia:, general.,his... | 11 |
subjective:, this 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. it cleared for awhile. this has been an intermittent problem. n... | 8 |
title of operation: , placement of right new ventriculoperitoneal (vp) shunts strata valve and to removal of right frontal ommaya reservoir.,indication for surgery: , the patient is a 2-month-old infant, born premature with intraventricular hemorrhage and ommaya reservoir recommendation for removal and replacement with... | 23 |
preoperative diagnosis: , recurrent right inguinal hernia, as well as phimosis.,postoperative diagnosis:, recurrent right inguinal hernia, as well as phimosis.,procedure performed: , laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,anesthesia: , general endotracheal.,complications: , non... | 38 |
history of present illness: , in short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with bmi of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremiti... | 2 |
preoperative diagnosis:, positive peptic ulcer disease.,postoperative diagnosis:, gastritis.,procedure performed: , esophagogastroduodenoscopy with photography and biopsy.,gross findings:, the patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer d... | 14 |
history: ,this 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. no confirmed prior history of heart attack, myocardial infarction, heart failure. history dates back to about six months of intermittent shortness of breath, intermittent very slight e... | 3 |
preoperative diagnosis: ,persistent abnormal uterine bleeding after endometrial ablation.,postoperative diagnosis: , persistent abnormal uterine bleeding after endometrial ablation.,procedure performed: , total abdominal hysterectomy (tah) with a right salpingo-oophorectomy.,complications: , none.,estimated blood loss... | 38 |
procedure: , colonoscopy.,preoperative diagnoses: , rectal bleeding and perirectal abscess.,postoperative diagnosis: , perianal abscess.,medications:, mac.,description of procedure: ,the olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum an... | 38 |
technique: , sequential axial ct images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc optiray 350 intravenous contrast.,findings: , the heart size is normal and there is no pericardial effusion. the aorta and great vessels are normal in caliber. the cen... | 33 |
history of present illness: ,the patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. the patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed so... | 27 |
preoperative diagnosis: , abdominal wall abscess.,postoperative diagnosis: , abdominal wall abscess.,procedure: , incision and drainage (i&d) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,anesthesia: , lma.,indications: , patient... | 38 |
reason for consultation:, thrombocytopenia.,history of present illness:, mrs. xxx is a 17-year-old lady who is going to be 18 in about 3 weeks. she has been referred for the further evaluation of her thrombocytopenia. this thrombocytopenia was detected on a routine blood test performed on the 10th of june 2006. he... | 5 |
indication: , rectal bleeding.,premedication:, see procedure nurse ncs form.,procedure: , | 14 |
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 n... | 15 |
preoperative diagnoses,1. basal cell nevus syndrome.,2. cystic lesion, left posterior mandible.,3. corrected dentition.,4. impacted teeth 1 and 16.,5. maxillary transverse hyperplasia.,postoperative diagnoses,1. basal cell nevus syndrome.,2. cystic lesion, left posterior mandible.,3. corrected dentition.,4. im... | 7 |
preoperative diagnosis: ,esophageal rupture.,postoperative diagnosis:, esophageal rupture.,operation performed,1. left thoracotomy with drainage of pleural fluid collection.,2. esophageal exploration and repair of esophageal perforation.,3. diagnostic laparoscopy and gastrostomy.,4. radiographic gastrostomy tube ... | 3 |
procedure:, colonoscopy.,preoperative diagnosis: , follow up adenomas.,postoperative diagnoses:,1. two colon polyps, removed.,2. small internal hemorrhoids.,3. otherwise normal examination of cecum.,medications: , fentanyl 150 mcg and versed 7 mg slow iv push.,indications: , this is a 60-year-old white female with ... | 14 |
procedures: , left heart catheterization, left ventriculography, and left and right coronary arteriography.,indications: , chest pain and non-q-wave mi with elevation of troponin i only.,technique: ,the patient was brought to the procedure room in satisfactory condition. the right groin was prepped and draped in rout... | 38 |
reason for admission: , rectal bleeding.,history of present illness: ,the patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. he states that he had some stomach discomfort in the last 4 weeks. he has had some physic... | 5 |
chief complaint: , dysphagia and hematemesis while vomiting.,history of present illness: , this is a 53-year-old african american female with 15 years known history of hiv and hepatitis b, and known history of compensated heart failure, copd, who presented today with complaint of stuck food in her esophagus, bloody cou... | 14 |
reason for consultation: , mesothelioma.,history of present illness: , the patient is a 73-year-old pleasant caucasian male who is known to me from his previous hospitalization. he has also been seen by me in the clinic in the last few weeks. he was admitted on january 18, 2008, with recurrent malignant pleural effus... | 5 |
preoperative diagnosis:, cholelithiasis; possible choledocholithiasis. | 38 |
preoperative diagnoses:,1. blepharochalasia.,2. lower lid large primary and secondary bagging.,postoperative diagnoses:,1. blepharochalasia.,2. lower lid large primary and secondary bagging.,procedure: , quad blepharoplasty.,anesthesia: , general.,estimated blood loss: , minimal.,condition: , the patient did well.,... | 38 |
subjective:, this is a 1-month-old who comes in for a healthy checkup. mom says things are gone very well. he is kind of acting like he has got a little bit of sore throat but no fevers. he is still eating well. he is up to 4 ounces every feeding. he has not been spitting up. voiding and stooling well.,past medi... | 5 |
sample address,re: sample patient,dear doctor:,we had the pleasure of seeing abc and his mother in the clinic today. as you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. he has been having problems with wheezing, cough and shortness of breath over... | 29 |
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