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0 | A 23-year-old white female presents with complaint of allergies. | Allergy / Immunology | Allergic Rhinitis | SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. Sh... | allergy / immunology, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic, |
1 | Consult for laparoscopic gastric bypass. | Bariatrics | Laparoscopic Gastric Bypass Consult - 2 | PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has mu... | bariatrics, laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost |
2 | Consult for laparoscopic gastric bypass. | Bariatrics | Laparoscopic Gastric Bypass Consult - 1 | HISTORY OF PRESENT ILLNESS: , I have seen ABC today. He is a very pleasant gentleman who is 42 years old, 344 pounds. He is 5'9". He has a BMI of 51. He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. He is pursuing surgical attempts of weight loss to fee... | bariatrics, laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight, |
4 | 2-D Echocardiogram | Cardiovascular / Pulmonary | 2-D Echocardiogram - 2 | 1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the ... | cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary... |
5 | Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. | Bariatrics | Laparoscopic Gastric Bypass | PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS: ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for ma... | bariatrics, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric |
6 | Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
| Bariatrics | Liposuction | PREOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,PROCEDURES:... | bariatrics, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant, |
7 | 2-D Echocardiogram | Cardiovascular / Pulmonary | 2-D Echocardiogram - 3 | 2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imagin... | cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical... |
8 | Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs. | Bariatrics | Lipectomy - Abdomen/Thighs | PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:, Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:, General.,FINDINGS AND PROCEDURE:, With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks... | bariatrics, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs, |
10 | Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. | Bariatrics | Laparoscopic Gastric Bypass - 1 | PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-o... | bariatrics, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation |
12 | Cerebral Angiogram - moyamoya disease. | Neurology | Moyamoya Disease | CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a "flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found "passed out" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. Fo... | null |
13 | Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. | Bariatrics | Gastric Bypass Discussion - 3 | PAST MEDICAL HISTORY:, Significant for hypertension. The patient takes hydrochlorothiazide for this. She also suffers from high cholesterol and takes Crestor. She also has dry eyes and uses Restasis for this. She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleedi... | bariatrics, weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass, |
14 | Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32. | Dentistry | Bony Impacted Teeth Removal | PREOPERATIVE DIAGNOSIS:, Completely bony impacted teeth #1, #16, #17, and #32.,POSTOPERATIVE DIAGNOSIS: , Completely bony impacted teeth #1, #16, #17, and #32.,PROCEDURE: , Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,ANESTHESIA: , General nasotracheal.,COMPLICATIONS: , None.,CONDITION: ,... | dentistry, intraoral, bony impacted teeth, throat pack, buccal aspect, saline solution, gut sutures, envelope flap, periosteal elevator, |
15 | Preoperative visit for weight management with laparoscopic gastric banding | Bariatrics | Laparoscopic Gastric Banding - Preop Visit | HISTORY OF PRESENT ILLNESS: ,I have seen ABC today for her preoperative visit for weight management. I have explained to her the need for Optifast for weight loss prior to these procedures to make it safer because of the large size of her liver. She understands this.,IMPRESSION/PLAN:, We are going to put her on two w... | bariatrics, laparoscopic gastric banding, pulmonary embolism, lap banding, potential complications, gastric banding, banding, stomach, gastric, laparoscopic, weightNOTE |
16 | Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube. | Cardiovascular / Pulmonary | Tracheostomy | PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible b... | cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy,... |
17 | Patient status post lap band placement. | Bariatrics | Lap Band Adjustment | REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of ... | bariatrics, lap band adjustment, lap band placement, lap band, |
18 | Fertile male with completed family. Elective male sterilization via bilateral vasectomy. | Urology | Vasectomy - 4 | PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS: ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:, Fertile male with completed family.,MEDICATIONS: ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS: ,This 34-... | urology, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized, |
19 | The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone. | General Medicine | Airway Compromise & Foreign Body - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterect... | general medicine, diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway, |
20 | Whole body radionuclide bone scan due to prostate cancer. | Urology | Whole Body Radionuclide Bone Scan | INDICATION:, Prostate Cancer.,TECHNIQUE:, 3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections.,FINDINGS:, There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull. The u... | urology, prostate cancer, technetium, whole body, urinary retention, bone scan, radionuclide, |
21 | Patient discharged after laparoscopic Roux-en-Y gastric bypass. | Bariatrics | Gastric Bypass Summary | FINAL DIAGNOSES,1. Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. ,2. Hypertension. ,3. Obstructive sleep apnea, on CPAP.,OPERATION AND PROCEDURE: , Laparoscopic Roux-en-Y gastric bypass.,BRIEF HOSPITAL COURSE SUMMARY: ,This is a 30-year-old male, who presented recently to the Bariatric Center f... | bariatrics, medifast, laparoscopic roux-en-y gastric bypass, roux-en-y, bariatric clear liquids, gastric bypass, laparoscopic, gastric, bariatric, bypass, |
22 | Normal vasectomy | Urology | Vasectomy - 1 | DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. The left vas was grasped in between the fingers. The skin and vas were anesthetized with local anesthesia. The vas was grasped with an Allis clamp. Skin was incised and the vas deferens was regrasped with an... | urology, vasectomy, allis clamp, catgut, hemoclips, iris scissors, scrotal, scrotal supporter, testicular, vas, vas deferens, vas was grasped, deferens, clampsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not ce... |
23 | Voluntary sterility. Bilateral vasectomy. The vas deferens was grasped with a vas clamp. Next, the vas deferens was skeletonized. It was clipped proximally and distally twice. | Urology | Vasectomy | PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:, Bilateral vasectomy.,ANESTHESIA:, Local.,INDICATIONS FOR PROCEDURE: ,A gentleman who is here today requesting voluntary sterility. Options were discussed for voluntary sterility and he has elected to... | urology, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens |
26 | Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. | Urology | Urology Discharge Summary | PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lun... | urology, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate |
27 | Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia. | Urology | Umbilical Hernia Repair | PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL: ,The patient was prepped and draped in the sterile fashion. An infraumbilical ... | urology, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia, |
28 | Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation | Urology | Urology Letter | Sample Address,RE: Sample Patient,Wife's name: Sample Name,Dear Sample Doctor:,Mr. Sample Patient was seen on Month DD, YYYY, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan. He has remained azoospermic postoperatively. The operative note s... | urology, letter, urology letter, azoospermic, cryopreservation, specimen harvest, sperm harvesting, vasectomy, vasectomy reversal, fresh specimen, reversal, sperm, |
29 | Desire for sterility. Vasectomy. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas. | Urology | Vasectomy - 3 | PREOPERATIVE DIAGNOSIS:, Desire for sterility.,POSTOPERATIVE DIAGNOSIS:, Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped. Then, 1% lidocaine was used for anesthesia. The vas was i... | urology, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy |
30 | The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse. | Urology | Urinary Retention - Followup | HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after... | urology, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence, |
31 | This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again. | Urology | Urinary Retention | CHIEF COMPLAINT:, Urinary retention.,HISTORY OF PRESENT ILLNESS: , This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably sec... | null |
32 | Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. | Urology | Ureteral Calculus - Consult | CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS: ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower urete... | null |
33 | Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery. | Urology | Umbilical Hernia Repair - 1 | PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:, After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was ... | urology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical, |
34 | Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. | Urology | Urinary Frequency & Urgency - Followup | HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improve... | urology, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding |
35 | Ultrasound examination of the scrotum due to scrotal pain. Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. | Urology | Ultrasound Scrotum | EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS: ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. The left testicle measures 5.1 x 2.8 x 3.0 cm. There is no evidence of intratesticular masses. There is normal ... | urology, scrotal pain, epididymis, torsion, ultrasound examination, intratesticular masses, ultrasound, scrotal, testicles, scrotum, |
36 | Transurethral resection of a medium bladder tumor (TURBT), left lateral wall. | Urology | Transurethral Resection Of Bladder Tumor | PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley ... | urology, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria, |
37 | Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia. | Urology | TURP | PREOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,POSTOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,OPERATION PERFORMED: , Transurethral electrosurgical resection of the prostate.,ANESTHESIA: , General.,COMPLICATIONS:, None.,INDICATIONS FOR THE SURGERY:, This is a 77-year-old man with severe benign prost... | urology, benign prostatic hyperplasia, cystoscopy, foley catheter, turp, transurethral, bladder, bladder diverticula, electrosurgical, obturator, prostate, resectoscopic, transurethral resection, urinary retention, resection of the prostate, transurethral electrosurgical resection, anesthesia, hyperplasia, resection, p... |
38 | Transurethral resection of the bladder tumor (TURBT), large. | Urology | TURBT - 1 | PREOPERATIVE DIAGNOSIS: ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION: ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to ... | urology, transurethral resection of the bladder tumor, transurethral resection, bladder cancer, bladder tumor, bladder, turbt, insufficiency, tumor |
39 | The patient has a possibly torsion detorsion versus other acute testicular problem. | Urology | Testicular Pain | CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Beca... | null |
40 | Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy. | Urology | TURBT | PREOPERATIVE DIAGNOSIS: ,Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,POSTOPERATIVE DIAGNOSIS: , Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,TITLE OF OPERATION: , Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct ... | urology, transitional cell carcinoma, urinary bladder, bladder tumor, cystoscopy, transurethral resection, acmi panendoscope, foley catheter, cold cup biopsy forceps, ta nx mx, cold cup biopsy, laryngeal mask, bladder neck, bladder, biopsy, tumor, |
41 | Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning. | Urology | Spermatocelectomy, Epididymectomy, & Vasectomy | PREOPERATIVE DIAGNOSES:,1. Left spermatocele.,2. Family planning.,POSTOPERATIVE DIAGNOSES:,1. Left spermatocele.,2. Family planning.,PROCEDURE PERFORMED:,1. Left spermatocelectomy/epididymectomy.,2. Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Minimal.,SPECIMEN: , Left-sided spermat... | urology, partial vasectomy, spermatocele, epididymis, family planning, vas deferens, metzenbaum scissors, vasectomy, spermatocelectomy, epididymectomy, testicle, deferens, hemostats, electrocautery, |
42 | Left testicular swelling for one day. Testicular Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles. | Urology | Testicular Ultrasound | TESTICULAR ULTRASOUND,REASON FOR EXAM: ,Left testicular swelling for one day.,FINDINGS: ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on t... | urology, hypervascularity, bilateral hydroceles, epididymis, epididymitis, testicular ultrasound, ultrasound, flow, hydroceles, testicle, testicular, |
43 | Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis. | Urology | Salvage Cystectomy | PREOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequ... | urology, radiation cystitis, voiding dysfunction, retropubic prostatectomy, salvage radiation therapy, salvage cystectomy, indiana pouch continent cutaneous diversion, omental pedicle flap, ligasure, gia, stapler, gia stapler, vicryl sutures, radiation therapy, silk sutures, bladder, therapy, sutures, endotracheal, |
44 | Spermatocelectomy and orchidopexy | Urology | Spermatocelectomy | PREOPERATIVE DIAGNOSIS:, Right spermatocele.,POSTOPERATIVE DIAGNOSIS: ,Right spermatocele.,OPERATIONS PERFORMED:,1. Right spermatocelectomy.,2. Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: ,The patient is a 77-year-old male who co... | urology, orchidopexy, spermatocele, spermatocelectomy, scrotal |
45 | SPARC suburethral sling due to stress urinary incontinence. | Urology | Sling (SPARC Suburethral) | PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence. Intraoperatively, the bladder ... | urology, stress urinary incontinence, foley catheter, metzenbaum scissor, sparc, sparc mesh, bladder, orifice, perineum, sling, suburethral, ureteral, urethral hypermobility, vagina, vaginal vault, vulva, cystoscopy, suburethral sling, stress urinary, urinary incontinence, incontinence |
46 | Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery. | Urology | Scrotal Exploration | PREOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,POSTOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,PROCEDURE: , Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,ANESTHETIC:, A 0.25% Marcaine local w... | urology, de-torsed bilateral testes, testes fixation, bell clapper deformity, testicular torsion, subdartos pouch, tunica vaginalis, scrotal exploration, appendix testes, scrotal, testes, torsion, detorsion, insufflation, testis, |
47 | Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy. | Urology | Pyeloureteroscopy | PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:, Left obstructed renal ureteropelvic junction o... | urology, cystoscopy, pyeloureteroscopy, ureteropelvic junction obstruction, pseudomonas pyelonephritis, renal insufficiency, fortaz, ureteropelvic junction repair, nephrostomy tube, renal biopsy, renal pelvis, foley catheter, ureteropelvic junction, renal, ureteropelvic, |
48 | Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate. | Urology | Prostatectomy - Robotic Radical Retropubic | PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1. Radical retropubic prostatectomy, robotic assisted.,2. Bladder suspension.,ANESTHESIA:, General by intubation.,The patient understands his diagnosis, grade, stage and prognosis. He under... | urology, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy |
49 | A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago. | Urology | Pubic Cellulitis | DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:, A 16-month-old with history of penile swelling for 4 days. The patient was transferred for higher level of care. This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent. Apparently, the patient developed adhe... | null |
50 | Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer. | Urology | Prostatectomy - Radical Retropubic | PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA: ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man wit... | urology, prostate cancer, foley catheter, metzenbaum scissors, prostate, adenocarcinoma, bladder, lymphadenectomy, pelvic lymph node dissection, perivesical, prostatectomy, retropubic, urethra, radical retropubic prostatectomy, lymph node dissection, dorsal vein complex, radical retropubic, lymph node, dorsal vein, vei... |
51 | Radical retropubic nerve-sparing prostatectomy without lymph node dissection. | Urology | Prostatectomy - Nerve Sparing | PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: ... | urology, prostate cancer, foley catheter, gleason, psa, prostate, adenocarcinoma, bladder neck, core biopsy, figure-of-eight, lymph node dissection, nerve-sparing, prostatectomy, rectus fascia, retropubic, bladder neck dissection, dorsal vein complex, nerve sparing, perirectal fat, seminal vesicles, sutures, bladder, u... |
52 | A 65-year-old man with chronic prostatitis returns for recheck. | Urology | Prostatitis - Recheck | SUBJECTIVE:, The patient is a 65-year-old man with chronic prostatitis who returns for recheck. He follow with Dr. XYZ about every three to four months. His last appointment was in May 2004. Has had decreased libido since he has been on Proscar. He had tried Viagra with some improvement. He has not had any urinar... | null |
53 | Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical | Urology | Prostate Adenocarcinoma - H&P | HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing... | urology, gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate, |
54 | Prostate Brachytherapy - Prostate I-125 Implantation | Urology | Prostate Brachytherapy | PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound ... | urology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: 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... |
55 | Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy. | Urology | Pyeloplasty - Robotic | PROCEDURES:,1. Robotic-assisted pyeloplasty.,2. Anterograde right ureteral stent placement.,3. Transposition of anterior crossing vessels on the right.,4. Nephrolithotomy.,DIAGNOSIS:, Right ureteropelvic junction obstruction.,DRAINS:,1. Jackson-Pratt drain times one from the right flank.,2. Foley catheter times ... | urology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures, |
56 | Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus. | Urology | Retrograde Pyelogram & Cystourethroscopy | PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Right retrograde pyelogram.,3. Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:, Urine for culture and sensitivi... | urology, ureteropelvic junction, calculus, cystourethroscopy, retrograde pyelogram, double-j stent placement, double j stent, cone tip catheter, ureteral stent, ureteral orifice, ureteral catheter, retrograde, pyelogram, catheter, ureteral |
57 | Open radical retropubic prostatectomy with bilateral lymph node dissection. | Urology | Prostatectomy | PREOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:, This i... | urology, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac... |
58 | The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA. | Urology | Prostate Fossa Irradiation - Followup | HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. His urinary function had been stable until 2 days ago. Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated a... | null |
59 | Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck. | Urology | Prostate Adenocarcinoma - 4 | PHYSICAL EXAMINATION:, Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0. All other systems were normal.,PROCEDURES: ,Sextant biopsy of the prostate.,Radical prostatectomy: Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small ... | urology, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate, |
60 | Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles. | Urology | Prostate Adenocarcinoma - 3 | PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical. He stated that he was in excellent health and led an active life. His physical examination was normal for a man of his age. Chest x-ray and chemical screening blood work were within normal limits. Hi... | urology, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma |
61 | Patient presents to the Emergency Department with complaint of a bleeding bump on his penis. | Urology | Penile Mass - Emergency Visit | CHIEF COMPLAINT: , "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half... | urology, bump on penis, bleeding bump, glans, urethral meatus, penile mass, emergency department, penis, penile, pedunculated, bump, mass, |
62 | Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease. | Urology | Penile Prosthesis Replacement | PREOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesi... | urology, inflatable penile prosthesis, peyronie's disease, perineum, scrotum, penis, penile prosthesis, bovie cautery, corporal body, glans penis, pump, cylinders, penile, prosthesis, inflatable, corporal |
63 | Excision of penile skin bridges about 2 cm in size. | Urology | Penile Skin Bridges Excision | PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE: ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS: ,Same as above.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 ... | urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile, |
64 | Adenocarcinoma of the prostate. The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. | Urology | Prostate Adenocarcinoma | ADMISSION DIAGNOSIS: ,Adenocarcinoma of the prostate.,HISTORY:, The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5). The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7... | null |
65 | Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate. | Urology | Prostate Adenocarcinoma - 1 | HISTORY:, This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction. After catheterization, the patient underwent cystoscopy on 4/13. On 4/14 the patient underwent a transurethral resection of the p... | urology, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma, |
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