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800 | Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain. | Surgery | Facet Arthrogram & Injection | PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.... | surgery, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet, |
801 | Incompetent glottis. Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty. | Surgery | Fat Harvesting | PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:, Incompetent glottis.,OPERATION PERFORMED:,1. Fat harvesting from the upper thigh.,2. Micro-laryngoscopy.,3. Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesth... | surgery, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh |
802 | Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, righ... | Surgery | Femoral Artery Cannulation & Aortogram | PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD. Significant coronary artery diseas... | null |
803 | Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout. | Surgery | Fiberoptic Bronchoscopy | PREOPERATIVE DIAGNOSIS:, Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1. Bilateral upper lobe cavitary lung masses.,2. Final pending pathology.,3. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also c... | surgery, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe, |
804 | Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability. | Surgery | Fiberoptic Bronchoscopy - 1 | PREOPERATIVE DIAGNOSIS:,1. Hemoptysis.,2. History of lung cancer.,POSTOPERATIVE DIAGNOSIS:, Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:, Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:, General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COM... | surgery, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe, |
805 | External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation. | Surgery | External Cephalic Version | PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:, A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,The pa... | surgery, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine, |
806 | Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17. | Surgery | Extraoral I&D | PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of... | surgery, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth, |
807 | Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel. | Surgery | Facetectomy & Foraminotomy | PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet... | null |
808 | Left supraorbital deep complex facial laceration measuring 6x2 cm. Plastic closure of deep complex facial laceration measuring 6x2 cm. The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal ble... | Surgery | Facial Laceration Closure | PREOPERATIVE DIAGNOSIS:, Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lid... | surgery, plastic closure, facial laceration, deep complex facial laceration, steri strips, closure, bleeding, sterile, sutures, forehead, wound, supraorbital, facial, laceration |
809 | Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid. | Surgery | Eyelid Squamous Cell Carcinoma Excision | PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS: ,None.... | surgery, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis, |
810 | Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst. | Surgery | Exploratory Laparotomy - 2 | PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ... | surgery, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis, |
811 | Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent. | Surgery | Exploratory Laparotomy - 1 | PREOPERATIVE DIAGNOSIS:, History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES: ,1. History of perforated sigmoid diverticuli with Hartmann's procedure.,2. Massive adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions and removal.,3. Reversal of H... | surgery, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal |
812 | Left little finger extensor tendon laceration. Repair of left little extensor tendon. | Surgery | Extensor Tendon Repair | PREOPERATIVE DIAGNOSIS:, Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED: ,Repair of left little extensor tendon.,COMPLICATIONS:, None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year... | surgery, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor, |
813 | Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess. | Surgery | Exploratory Laparotomy & Colon Resection | PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1. Colovesical fistula.,2. Intraperitoneal abscess.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Low anterior colon resection.,3. Flexible colonoscopy.,4. Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY: ,Thi... | surgery, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula |
814 | Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia. | Surgery | Exploratory Laparotomy & Hernia Repair | PREOPERATIVE DIAGNOSIS:,1. Acute bowel obstruction.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1. Acute small bowel obstruction.,2. Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Release of small bowel obstruction.,3. Repair of periumbilical hernia.,ANESTHESIA: , General wit... | surgery, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction, |
815 | Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm. | Surgery | Excision - Skin Neoplasm | PREOPERATIVE DIAGNOSES:,1. Enlarging nevus of the left upper cheek.,2. Enlarging nevus 0.5 x 1 cm, left lower cheek.,3. Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1. Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2. Excision of the left lower cheek ... | surgery, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek |
816 | Re-excision of squamous cell carcinoma site, right hand. | Surgery | Excision of Squamous Cell Carcinoma | PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:, Local with monitored anesthesia care.,INDICAT... | surgery, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma |
817 | Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures | Surgery | Excision - Actinic Neoplasm | PREOPERATIVE DIAGNOSES:,1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5... | null |
818 | Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm. | Surgery | Excision - Keratotic Neoplasm | PREOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1. Enlarging dark keratoti... | surgery, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision, |
819 | Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed. | Surgery | Excision - Soft Tissue Mass | PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:, This 54-year-old male was evaluated in the office with a large right ... | surgery, electrocautery, soft tissue mass, subcutaneous, excision |
820 | Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. | Surgery | Exploratory Laparotomy | PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intub... | surgery, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach |
821 | Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. | Surgery | Ethmoidectomy & Nasal Polypectomy | PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Bilateral maxillary antrostomy.,3. Bilateral total ethmoidectomy.,4. Bilateral nasal polypectomy.,5. Right middle turbinate reduction.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS:, Approximately 50 cc.,INDICATION: , This is a 48-year-old fem... | surgery, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider, |
822 | Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted. | Surgery | Esophagoscopy & Foreign Body Removal - 1 | PRIMARY DIAGNOSIS:, Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:, Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:, Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed. Esophagus ... | surgery, esophagus, foreign body, esophagoscopy, esophageal, |
823 | Excision of bilateral chronic hydradenitis. | Surgery | Excision - Hydradenitis | PREOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,POSTOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,NAME OF OPERATION: , Excision of bilateral chronic hydradenitis.,ANESTHESIA:, Local.,FINDINGS: , This patient had previously had excision of hydradenitis. However, she had residual disease in both ax... | surgery, hydradenitis, elliptical incision, bilateral hydradenitis, chronic hydradenitis, axilla, excision, chronic, |
824 | Esophagogastroduodenoscopy with pseudo and esophageal biopsy. Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough. | Surgery | Esophagogastroduodenoscopy with Biopsies -2 | PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1. Hiatal hernia.,2. Reflux esophagitis.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:, Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY... | surgery, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd, |
825 | Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion. | Surgery | Esophagogastroduodenoscopy with Biopsies - 1 | PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:, Abdominal pain.,FINDINGS:, Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE... | surgery, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid, |
826 | Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location. | Surgery | Esophagoscopy & Foreign Body Removal | PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasa... | surgery, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus, |
827 | Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. Malnutrition and dysphagia with two antral polyps and large hiatal hernia. | Surgery | Esophagogastroduodenoscopy - 9 | PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylo... | surgery, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal |
828 | Esophagogastroduodenoscopy with photo. Insertion of a percutaneous endoscopic gastrostomy tube. Neuromuscular dysphagia. Protein-calorie malnutrition. | Surgery | Esophagogastroduodenoscopy & Gastrostomy Tube Insertion | PREOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1. Esophagogastroduodenoscopy with photo.,2. Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:, IV se... | surgery, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube, |
829 | Positive peptic ulcer disease. Gastritis. Esophagogastroduodenoscopy with photography and biopsy. The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease. | Surgery | Esophagogastroduodenoscopy - 7 | 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... | surgery, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach |
830 | Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy. | Surgery | Esophagogastroduodenoscopy with Biopsies | PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,3. Alkaline reflux gastritis.,4. Gastroparesis.,5. Probable Billroth II anastomosis.,6. Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PE... | surgery, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biop... |
831 | Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp. Esophagogastroduodenoscopy with photos and antral biopsy. | Surgery | Esophagogastroduodenoscopy - 8 | PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Duodenal polyp.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks ... | surgery, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral, |
832 | Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. | Surgery | Esophagogastroduodenoscopy - 6 | PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. ... | surgery, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.T... |
833 | Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy. | Surgery | Esophagogastroduodenoscopy - 4 | PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage. Currently, he has a fistula from his anterior abdominal wall out. It... | surgery, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy |
834 | Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. | Surgery | Esophagogastroduodenoscopy - 5 | MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx. The patient was sedated with the above medications. The Olympus video panend... | surgery, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE |
835 | Esophagogastroduodenoscopy performed in the emergency department. | Surgery | Esophagogastroduodenoscopy - 13 | PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1. Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric ... | surgery, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus, |
836 | Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy. | Surgery | Esophagogastroduodenoscopy - 3 | PROCEDURES:, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:, History and physical examination was per... | surgery, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy, |
837 | Esophagogastroduodenoscopy with biopsy. | Surgery | Esophagogastroduodenoscopy - 2 | PROCEDURE:, Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:, The child with history of irritability and diarrhea with gastroesophageal reflux. Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease. He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal contr... | surgery, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy |
838 | Esophagogastroduodenoscopy, photography, and biopsy. Gastroesophageal reflux disease, hiatal hernia, and enterogastritis. | Surgery | Esophagogastroduodenoscopy - 12 | PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,3. Enterogastritis.,PROCEDURE PERFORMED: ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdo... | surgery, biopsy, gastroesophageal reflux, gastroesophageal reflux disease, duodenal bulb, gastroesophageal junction, hiatal hernia, enterogastritis, endoscopy, esophagogastroduodenoscopy, gastroesophageal, |
839 | Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy. | Surgery | Esophagogastroduodenoscopy - 11 | PREOPERATIVE DIAGNOSIS:, Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-ye... | surgery, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope |
840 | Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids. | Surgery | Esophagogastroduodenoscopy - 1 | PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids. The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS:... | surgery, esophagogastroduodenoscopy, esophageal, biopsies, endoscope |
841 | Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia | Surgery | Esophagogastroduodenoscopy | PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent an... | surgery, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia, |
842 | Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy. | Surgery | Esophagogastrectomy, Jejunostomy, & Chest Tubes | OPERATION,1. Ivor-Lewis esophagogastrectomy.,2. Feeding jejunostomy.,3. Placement of two right-sided #28-French chest tubes.,4. Right thoracotomy.,ANESTHESIA: ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a tho... | surgery, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach, |
843 | Direct laryngoscopy and esophagoscopy with removal of foreign body | Surgery | Esophageal Foreign Body Removal | PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body.,PROCEDURES PERFORMED:,1. Direct laryngoscopy with intubation by surgeon.,2. Rigid tracheoscopy.,3. Rigid esophagoscopy with removal of foreign body.,INDICATIONS: , The patient is an 8-month-old Hispanic male, who p... | surgery, rigid tracheoscopy, rigid esophagoscopy, subglottic, supraglottic, glottic, removal of foreign body, level of the cricopharyngeus, esophageal foreign body, foreign body, rigid endoscope, direct laryngoscopy, emergency department, parson's laryngoscope, foreign, esophagoscopy, tracheoscopy, transorally, laryngo... |
844 | Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain. | Surgery | Esophagogastroduodenoscopy - 10 | PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS: ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:, IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to th... | surgery, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral, |
845 | Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy. | Surgery | ERCP | PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesi... | surgery, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology |
846 | Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar. | Surgery | Escharotomy | PREOPERATIVE DIAGNOSES:, 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with im... | surgery, lateral escharotomy, medial escharotomy, eschar, anterior thorax, underlying subcutaneous tissue, bilateral upper extremities, impending compartment syndrome, arm burn, extremity burns, humeral head, burn eschar, compartment syndrome, escharotomy, humeral, burns |
847 | Epigastric herniorrhaphy. Epigastric hernia. | Surgery | Epigastric Herniorrhaphy | PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:, Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely. The hernia mass had b... | surgery, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy, |
848 | Epididymectomy | Surgery | Epididymectomy | EPIDIDYMECTOMY,OPERATIVE NOTE: ,The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. A small amount of clear fluid was expressed. The tunica vaginalis was opened and the testicle w... | surgery, scrotal incision, 0.25% marcaine, bovie, epididymectomy, chromic catgut, epididymis, fluid, scalpel, scrotum, sterile dressing, testicle, tunica vaginalisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does no... |
849 | Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters. | Surgery | Endotracheal Intubation - 1 | PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE: ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total... | surgery, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE |
850 | A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back. | Surgery | Epidermal Autograft | PREOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1. Epidermal autograft on Integra to the... | surgery, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft, |
851 | Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia. | Surgery | Epidural Hematoma Evacuation | PREOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Ce... | surgery, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia, |
852 | The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. | Surgery | Endovascular Abdominal Aortic Aneurysm Repair | PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:, Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. A Gor... | surgery, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries, |
853 | Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. | Surgery | Endotracheal Intubation | PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subse... | surgery, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma |
854 | Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping. | Surgery | Epidurogram | PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION... | surgery, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle |
855 | Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding. | Surgery | Endoscopy With Biopsy | PROCEDURE:, Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained. Outlining the risks, benefits... | surgery, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy, |
856 | Upper gastrointestinal endoscopy. | Surgery | Endoscopy | PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:, Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1. Severe duodenitis.,2. Gastroesophageal junction small ulceration seen.,3. No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position. Olympus scope was inserte... | surgery, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding |
857 | Normal upper GI endoscopy. | Surgery | Endoscopy Template | INDICATIONS:, Dysphagia.,PREMEDICATION:, Topical Cetacaine spray and Versed IV.,PROCEDURE:,: The scope was passed into the esophagus under direct vision. The esophageal mucosa was all unremarkable. There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis. The... | surgery, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope |
858 | Intermittent rectal bleeding with abdominal pain. | Surgery | Endoscopy - 4 | PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:, The patient was taken to the GI lab and placed in the left lateral supine position. Continuous pulse oximetry and blood pressure monitoring were in place.... | surgery, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal |
859 | Endoscopic carpal tunnel release. Left carpal tunnel syndrome. | Surgery | Endoscopic Carpal Tunnel Rlease | PREOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIONS PERFORMED:, Endoscopic carpal tunnel release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , With the patient unde... | surgery, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse, |
860 | Upper endoscopy, patient with dysphagia. | Surgery | Endoscopy - 1 | PROCEDURE:, Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1. GERD, biopsied.,2. Distal esophageal reflux-induced stricture, dilated to 18 mm.,3. Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white... | surgery, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux, |
861 | Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis. | Surgery | Endoscopic Carpal Tunnel & de Quervain's Release | PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lid... | surgery, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic, |
862 | Patient with dysphagia. | Surgery | Endoscopy - 3 | PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:, Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 m... | surgery, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon |
863 | Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors. | Surgery | Electrofulguration - Bladder Tumor | PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:, Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:, General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE... | surgery, bladder neck, bladder tumors, cystoscopy, tur, electrofulguration, bladder |
864 | Melena and solitary erosion over a fold at the GE junction, gastric side. | Surgery | Endoscopy - 2 | PREOPERATIVE DIAGNOSIS:, Melena.,POSTOPERATIVE DIAGNOSIS:, Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:, The Olympus gastroscope was used. The scope was placed in the upper esophagus under direct visit. The esophageal mucosa was entirely norma... | surgery, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion, |
865 | Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty. | Surgery | Endoscopic Sinus Surgery | PREOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertroph... | null |
866 | Left elbow manipulation and hardware removal of left elbow. | Surgery | Elbow Manipulation | PREOPERATIVE DIAGNOSIS:, Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1. Left elbow manipulation.,2. Hardware removal of left elbow.,ANESTHESIA: ,Surgery was performed under general anesthesia.,COMPLICATIONS:, There were no intraoperative complicati... | surgery, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware, |
867 | Emergency cesarean section. | Surgery | Emergency C-section. | PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA: ,... | surgery, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine, |
868 | Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube. | Surgery | EGD with Biopsy - 1 | PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago. She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ... | surgery, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, dista... |
869 | Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods. | Surgery | EGD with Biopsy - 2 | TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:, Abdominal pain.,POSTOPERATIVE DIAGNOSIS:, Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS: ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characteri... | surgery, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy, |
870 | Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position. | Surgery | Electronystagmogram | PROCEDURE: ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze. Simultaneous recordings... | surgery, silver chloride biopotential electrodes, inferior orbital margins, lateral canthi, vestibular dysfunction, prominent nystagmus, head hanging, electronystagmogram, eyes, nystagmus, |
871 | Common description of EGD | Surgery | EGD Template - 4 | null | surgery, lateral supine position, stomach, duodenum, stricture, egd, advanced, scopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical tran... |
872 | EGD with dilation for dysphagia. | Surgery | EGD with Dilation | INDICATION: , | surgery, egd, hurricaine spray, olympus endoscope, savary wire, cricopharyngeus, decubitus, dilator, duodenum, dysphagia, esophagus, hiatal hernia, peptic, pylorus, stomach, tortuosity, egd with dilation, tortuous, scope, hiatal, hernia, |
873 | Common description of EGD. | Surgery | EGD Template - 2 | 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 ... | surgery, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE |
874 | EGD with photos and biopsies. This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently. | Surgery | EGD With Photos & Biopsies. | 1. Odynophagia.,2. Dysphagia.,3. Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Hiatal hernia.,PROCEDURE PERFORMED: EGD with photos and biopsies.,GROSS FINDINGS: This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and ody... | surgery, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia, |
875 | EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis. | Surgery | EGD & PEG Tube Placement | PREOPERATIVE DIAGNOSES:,1. protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1. Protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,3. Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHES... | surgery, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis |
876 | Common description of EGD. | Surgery | EGD Template - 3 | without difficulty, into the upper GI tract. The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected. All structures were visually normal in appearance. Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent... | surgery, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. M... |
877 | EGD and colonoscopy. Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass. | Surgery | EGD & Colonoscopy | PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Normal colon with no evidence of bleeding.,2. Hiatal hernia.,3. Fundal gastritis with polyps.,4. Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN: ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-o... | surgery, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy, |
878 | Esophagogastroduodenoscopy and colonoscopy with polypectomy | Surgery | EGD - Colonoscopy - Polypectomy | PROCEDURES:,1. Esophagogastroduodenoscopy.,2. Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1. History of esophageal cancer.,2. History of colonic polyps.,POSTOPERATIVE FINDINGS:,1. Intact surgical intervention for a history of esophageal cancer.,2. Melanosis coli.,3. Transverse colon polyps in the setti... | null |
879 | Common description of EGD. | Surgery | EGD Template - 1 | null | surgery, duodenal mucosa, duodenal, esophageal mucosa, fundus, egd, entire, mucosaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transc... |
880 | Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus. | Surgery | EGD - 1 | HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture... | surgery, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus, |
881 | Esophagogastroduodenoscopy, patient with dysphagia. | Surgery | EGD - 2 | PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attent... | surgery, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia |
882 | Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm. | Surgery | Ear Laceration Repair | PREOPERATIVE DIAGNOSIS:, Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:, Bilateral ear laceration deformities.,PROCEDURE:,1. Repair of left ear laceration deformity Y-V plasty 2 cm.,2. Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine lo... | surgery, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair |
883 | Right ear examination under anesthesia. Right tympanic membrane perforation along with chronic otitis media. | Surgery | Ear Examination | PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation foll... | surgery, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation, |
884 | Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography. | Surgery | Dual Chamber ICD Implantation | PROCEDURE:,1. Implantation, dual chamber ICD.,2. Fluoroscopy.,3. Defibrillation threshold testing.,4. Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room. The patient was prepped and draped in a sterile fashion. Using modified Seldinger technique, the lef... | surgery, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoro... |
885 | Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy. | Surgery | Ear Cartilage Graft | PREOPERATIVE DIAGNOSES: ,1. Posttraumatic nasal deformity.,2. Nasal obstruction.,3. Nasal valve collapse.,4. Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1. Posttraumatic nasal deformity.,2. Nasal obstruction.,3. Nasal valve collapse.,4. Request for cosmetic change wi... | surgery, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartil... |
886 | Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement. | Surgery | Dual Chamber Generator Replacement | REFERRAL INDICATIONS,1. Pacemaker at ERI.,2. History AV block.,PROCEDURES PLANNED AND PERFORMED:, Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1. Ancef 1 g.,2. Versed 2 mg.,3. Fentanyl 50 mcg.,CLINICAL HISTORY: ,The patient is a pleasant patient who presented... | null |
887 | Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were ... | Surgery | Dorsal Ramus & Branch Block | PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its... | surgery, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block, |
888 | Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. | Surgery | Dorsal Ganglion - Excision | PREOPERATIVE DIAGNOSIS:, Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:, Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:, Excision dorsal ganglion, right wrist.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:, minutes.,DESCRIPTION OF PROCEDURE: , Wit... | surgery, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion |
889 | Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet. | Surgery | Diverticulectomy & Laparotomy | PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1. Diagnostic laparotomy.,2. Exploratory laparotomy.,3. Meckel's diverticulectomy.,4. Open incidental appendectomy.,5. Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BL... | null |
890 | Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort. | Surgery | Dupuytren Disease Excision | PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS: ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED: ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS: ,Non... | surgery, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger |
891 | Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment. | Surgery | Dorsal Extensor Compartment Release | PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:, Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , B... | surgery, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet, |
892 | Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port. | Surgery | Double Lumen Port Inserstion | 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... | surgery, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter, |
893 | Direct laryngoscopy and bronchoscopy. | Surgery | Direct Laryngoscopy | PREOPERATIVE DIAGNOSIS:, Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:, General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table. General inhala... | surgery, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis, |
894 | Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1. | Surgery | Diskectomy & Fusion | PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:, Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED: ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN D... | surgery, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion, |
895 | Traumatic injury to bilateral upper extremities. Dressing change under anesthesia. This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change. | Surgery | Dressing Change | PREOPERATIVE DIAGNOSIS: , Traumatic injury to bilateral upper extremities.,POSTOPERATIVE DIAGNOSIS: , Traumatic injury to bilateral upper extremities.,PROCEDURE: , Dressing change under anesthesia.,PREOPERATIVE INDICATIONS: ,This 6 year old was involved in a traumatic accident. She presents today for evaluation and d... | surgery, bandages, traumatic injury, upper extremities, dressing change, traumatic, dressing, injury, |
896 | Fractional dilatation and curettage | Surgery | Dilatation & Curettage - D&C | PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED: ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding. An office endometrial b... | surgery, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage |
897 | Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs | Surgery | Discectomy, Osteophytectomy, & Foraminotomy | PREOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at... | null |
898 | Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. | Surgery | Dilation & Evacuation | PREOPERATIVE DIAGNOSIS:, 12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS: ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding f... | surgery, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina, |
899 | Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy. | Surgery | Diskectomy | PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,E... | surgery, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep, |
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