test_file.csv

description,medical_specialty
 An example/template for meatotomy.,39
" Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.",25
 Neurologic consultation was requested to assess and assist with seizure medication.,22
" Multiple sharp force injuries, involving chest and abdomen, multiple incised-stab wounds of the neck, and multiple incised or cutting wounds.",1
 The patient with atypical type right arm discomfort and neck discomfort.,3
 Implantation of a dual chamber permanent pacemaker,3
 Right lower pole renal stone and possibly infected stent.  Cysto stent removal.,39
" Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",38
 Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar.,3
" Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.",38
" The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. ",10
 A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain.  MI has been ruled out.  She has been referred for an exercise echocardiogram.,3
 MRI Brain: Thrombus in torcula of venous sinuses.,22
" Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.",14
" Esophagogastroduodenoscopy, photography, and biopsy.  Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.",38
" Total knee replacement.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.",38
" Exploratory laparotomy.  Extensive lysis of adhesions.  Right salpingo-oophorectomy.   Pelvic mass, suspected right ovarian cyst.",38
 The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,5
 A routine return appointment for a 71-year-old woman with chronic atrial fibrillation.  Chief complaint today is shortness of breath.,3
 An example of normal ENT exam.,11
" An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",5
 Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. ,38
 Left partial nephrectomy due to left renal mass.,21
 A male patient presented for evaluation of chronic abdominal pain.,5
" 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. ",5
" A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.",5
" Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.  CT abdomen without contrast and CT pelvis without contrast.",14
 Ultrasound of the right mandibular region.,33
 MRI of lumbar spine without contrast to evaluate chronic back pain.,22
" Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.",15
 Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. ,11
 Modified radical mastectomy.  An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further. ,38
" Desire for sterility.  Vasectomy.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.",39
" Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.",5
 Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,6
" MRI Brain, Carbon Monoxide poisoning.",15
 Normal child physical exam template.,25
" Flexor carpi radialis and palmaris longus repair.  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.",27
" GI Consultation due to rectal bleeding, positive celiac sprue panel",5
" Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.",38
 Bilateral endoscopic proximal shunt revision and a distal shunt revision.,23
 Right hemothorax.  Insertion of a #32 French chest tube on the right hemithorax.  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion.,3
 Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.,30
" Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.",38
 Laparoscopic tubal fulguration.,38
 Patient is here to discuss possible open lung biopsy.,3
" The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.",3
" Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.",39
  Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation.,27
 Circumcision in an older person,38
" 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. ",39
 CT Abdomen and Pelvis with contrast ,14
 Endoscopic third ventriculostomy.,23
" Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.",33
 Dobutamine stress test for atrial fibrillation.,33
 Template for History and Physical for a newborn.,15
 Patient returns for his first followup after shunt surgery.,23
" Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.",39
 Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,23
" Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",5
" Laparotomy and myomectomy.   Enlarged fibroid uterus and blood loss anemia.  On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.",24
 DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. ,38
 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,38
" Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.",27
 The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. ,3
 Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.,38
" Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).",24
 Significant pain in left lower jaw.,12
  CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.,27
" Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  ",26
 Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.,38
"  Rotator cuff tear, right shoulder.  Superior labrum anterior and posterior lesion (peel-back), right shoulder.  Arthroscopy with arthroscopic SLAP lesion.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.",38
 Right basilic vein transposition.  End-stage renal disease with need for a long-term hemodialysis access.  Excellent flow through fistula following the procedure.,21
" The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.",35
 Port insertion through the right subclavian vein percutaneously under radiological guidance.  Metastatic carcinoma of the bladder and bowel obstruction.,38
 Lexiscan Nuclear Myocardial Perfusion Scan.  Chest pain.  Patient unable to walk on a treadmill.  Nondiagnostic Lexiscan.  Normal nuclear myocardial perfusion scan.,3
 Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals. ,14
 Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,38
" Laparoscopy with ablation of endometriosis.  Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.",24
" Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.",23
" Followup of left hand discomfort and systemic lupus erythematosus.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",35
" Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.",38
 Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation ,38
" Hardware removal, right ulnar",27
" Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. ",36
 Full-mouth extraction of teeth and alveoloplasty in all four quadrants.,7
 The patient was referred for evaluation of cataracts bilaterally,26
" Circumcision.   A dorsal slit was made, and the prepuce was dissected away from the glans penis.",39
 Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope.,38
" A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.  ",27
 Orchiopexy & inguinal herniorrhaphy.,39
 Desires permanent sterilization.  Laparoscopic bilateral tubal occlusion with Hulka clips.,24
" Left flank pain, ureteral stone.",15
" Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.",5
 Phacoemulsification with posterior chamber intraocular lens - Sample/Template.,26
 Ophthalmology followup visit note.,35
 Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak. ,22
" Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).",15
" Hematemesis in a patient with longstanding diabetes.   Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.  Mallory-Weiss tear, successful BICAP cautery. ",38
" True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.",38
" MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.",16
" Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.",5
 Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,22
" Laparoscopic cholecystectomy.  Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.",10
 Burr hole and insertion of external ventricular drain catheter.,38
" Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.",38
 A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina.,35
 Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.,38
 Sore throat - Upper respiratory infection.,35
 Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,38
 Noncontrast CT abdomen and pelvis per renal stone protocol.,21
 Most commonly used phrases in physical exam.,15
 MRI Brain: Subacute right thalamic infarct.,33
 Standard Laparoscopic Cholecystectomy Operative Note.,38
 Diagnostic Mammogram and ultrasound of the breast.,24
 Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,3
" Morbid obesity.  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",38
" Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",24
" Echocardiographic examination.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.",3
 Right carpal tunnel release.,38
" Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",38
 Laparoscopic cholecystectomy.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,14
 Electroencephalographic findings and interpretation,36
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",25
" Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",5
 Reflex sympathetic dystrophy of both lower extremities.,20
" Laparoscopy with left salpingo-oophorectomy.  Left adnexal mass/ovarian lesion.  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  ",38
" Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.",3
" Left hemothorax, rule out empyema.  Insertion of a 12-French pigtail catheter in the left pleural space.",38
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.",33
 Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.  Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.,38
 Pitocin was started quickly to allow for delivery as quickly as possible.  Baby was delivered with a single maternal pushing effort with retraction by the forceps.,24
 An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,35
 Diagnostic laparoscopy and drainage of cyst.,38
 Tonsillectomy and adenoidectomy.  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,11
 Hyperfractionation.  This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  ,33
 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. ,31
" Cesarean Section.  An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. ",38
" Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.",28
 Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,38
" The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  ",29
" Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, 
and congestive heart failure.",15
" Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.  ",27
 1-month-old for a healthy checkup - Well child check,5
" The patient with gradual onset of a headache problem, located behind both eyes.",22
 The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.  The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,35
 PICC line insertion,3
 Trigger thumb release.  A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  ,27
 The patient with continued problems with her headaches. ,15
 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,2
" Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.  ",22
" Sample normal ear, nose, mouth, and throat exam.",5
 Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation.,21
 Benign prostatic hypertrophy and urinary retention.  Cystourethroscopy and transurethral resection of prostate (TURP).,39
 A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.,15
" A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study. ",30
 Ultrasound of pelvis - menorrhagia.,24
" Intractable epilepsy, here for video EEG.",22
 Newborn circumcision.  The penile foreskin was removed using Gomco. ,39
" Excision of foreign body, right foot and surrounding tissue.  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.",27
" 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",29
" The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.  Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",38
 Pelvic Pain and vaginal discharge,24
 Small office note on premature retina and vitreous.,25
 Patient with dysphagia.,14
" Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",3
" Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.
  ",23
 This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.,12
 Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.,5
 Direct laryngoscopy and bronchoscopy.,11
 MRI head without contrast.,33
" Marginal B-cell lymphoma, status post splenectomy.  Testicular swelling - possible epididymitis or possible torsion of the testis.",16
" Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.",22
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",15
" The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ",5
" Macular edema, right eye.  Insertion of radioactive plaque, right eye with lateral canthotomy.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy. ",26
" History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle.  Insertion of tissue expander to the medial and lateral wound.",38
 Right inguinal hernia.    Right direct inguinal hernia repair with PHS mesh system.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease. ,39
" Bilateral open mandible fracture, open left angle and open symphysis fracture.  Closed reduction of mandible fracture with MMF.",7
" Nonhealing right ankle stasis ulcer.  A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery. ",15
" Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.  Excision of nerve lesion in the left third interspace.
",27
 The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.,24
 MRI - Arteriovenous malformation with hemorrhage.,33
 Appendicitis.  Laparoscopic appendectomy.   CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.,38
 Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture.  Closed reduction and screw fixation of right femoral neck fracture.  Retrograde femoral nail using a striker T2 retrograde nail.  Irrigation and debridement of knee and elbow abrasions.,27
"  Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.",38
 Vitrectomy under general anesthesia,26
" Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa.  Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.",27
" MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.",33
 Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.,27
 Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,27
" Primary low transverse cervical cesarean section.   Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.",38
 The patient is brought in by an assistant with some of his food diary sheets.,9
 CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall.,33
" Chief complaint of chest pain, previously diagnosed with hyperthyroidism.",13
 Repair of bilateral cleft of the palate with vomer flaps.,38
" Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.",38
" Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2",15
" Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft.  Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.",38
 Iron deficiency anemia.  She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,5
" Colonoscopy - Diarrhea, suspected irritable bowel",38
 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,38
" Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.",12
" Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.",22
 Common description of colonoscopy,14
 Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,35
 Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea.,24
 Sample male exam and review of systems.,15
" Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.",11
 Nerve root decompression at L45 on the left side.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.  Interpretation of radiograph.,38
" 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.  ",39
 The patient was admitted after undergoing a drawn out process with a small bowel obstruction.,3
 Laparoscopic resection of cecal polyp.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  ,38
 Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea.,38
 Vaginal Hysterectomy.  A weighted speculum was placed in the posterior vaginal vault.  The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips.,24
 Endoscopic carpal tunnel release.  Left carpal tunnel syndrome.,38
 Consultation because of irregular periods and ovarian cyst.,5
 Tilt table test.  A patient with past medical history of syncope.  The patient is also complaining of dizziness.,3
 Prostate adenocarcinoma and erectile dysfunction - Pathology report.,19
" Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",5
 13 years old complaining about severe ear pain - Chronic otitis media.,5
" Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.",27
 Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.,38
" Placement of right external iliac artery catheter via left femoral approach, arteriography of the right iliac arteries, primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon, open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.",38
 A 10 years of age carries a diagnosis of cystic fibrosis,3
 Sample Radiology report of knee (growth arrest lines).,27
" Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.",11
" Medical management, status post left total knee arthroplasty.",27
 Bilateral carotid ultrasound.,33
 A 12-year-old with discoid lupus on the control with optimal regimen.,34
" Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.",38
 General Medicine SOAP note.,15
" Fever, otitis media, and possible sepsis.",10
" Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.",27
" External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  ",38
" An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",15
" Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.",11
 Psychiatric Consultation of patient with recurring depression.,32
"  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.",10
 Patient presents to the Emergency Department with complaint of a bleeding bump on his penis.,12
" Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",3
"  Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.",3
 Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,38
" Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.",33
" Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ",38
 Laparoscopic appendectomy.  Acute appendicitis.,38
 Bilateral lower extremity ultrasound for deep venous thrombus.,33
" Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.",3
" Bilateral Mammogram, (abnormal) additional views requested",24
" Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.",38
 Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,33
 Consultation for finger triggering and locking.,27
" Plantar fascitis, left foot.  Partial plantar fasciotomy.",38
 A two week well-child check.,5
" Uvulopalatopharyngoplasty and tonsillectomy.   The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.",11
 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,38
" Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.",22
" Bipolar disorder, apparently stable on medications.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.",32
 The patient had undergone mitral valve repair about seven days ago. ,38
 Open cholecystectomy (attempted laparoscopic cholecystectomy).,14
" Normal Physical Exam Template.  Well developed, well nourished, alert, in no acute distress. ",25
 This is a 95.5-hour continuous video EEG monitoring study.,33
 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,38
 An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,15
 Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,27
" Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.",39
 Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.,3
 The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,22
" Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.",38
 Cerebral Angiogram - moyamoya disease.,22
" Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.",27
 Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress.,15
 A 17-year-old male with oligoarticular arthritis of his right knee.,34
" Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",38
 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,14
 MRI Brain and Brainstem - Falling (Multiple System Atrophy),33
" Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.",5
" Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.",38
" Intramuscular lipoma, right upper extremity.  Excision of intramuscular lipoma with flap closure.",38
" The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",16
 Right carpal tunnel release.  Right carpal tunnel syndrome.  This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,38
 Bilateral pleural effusion.  Removal of bilateral #32 French chest tubes with closure of wound.,38
" Selective coronary angiography, left heart catheterization, and left ventriculography.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.",38
 Discharge summary of a patient presenting with a large mass aborted through the cervix.,10
 Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex.,6
" Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.",3
 Colonoscopy due to hematochezia and personal history of colonic polyps.,38
" Femoroacetabular impingement.  Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.",38
 Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix.,24
 Intrauterine pregnancy at term with previous cesarean.   Desired sterilization.  Status post repeat low transverse cesarean and bilateral tubal ligation.,10
 Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,5
 OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.,24
 Holter monitoring - For bradycardia and dizziness.,3
" This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. ",0
 Flexible Sigmoidoscopy.,38
 Pulmonary function test.  Mild restrictive airflow limitation.  Clinical correlation is recommended.,3
" Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",39
 Ruptured globe with full-thickness corneal laceration repair - Sample/Template.,26
 Nausea and feeling faint.  She complains of some nausea.  She feels weak.  The patient is advised to put salt on her food for the next week.  ,12
 MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.,33
 Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath.,5
" A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. ",3
 Pulmonary Function Test to evaluate dyspnea.,3
 Cardiac catheterization and coronary intervention report.,38
" Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",38
" Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.",5
" A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.",3
 Complete heart block with pacemaker malfunction and  a history of Shone complex.,3
" Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.",27
" The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. ",12
" First Pap smear, complaining of irregular periods.  - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.",5
 Spontaneous controlled sterile vaginal delivery performed without episiotomy.,38
 Pediatric Gastroenterology - History of gagging.,5
" D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.",24
" He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again. ",22
 3-Dimensional Simulation.  This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.,16
" Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy",14
" Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.",27
" The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. ",15
" Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction",3
 The patient had spraying of urine and ballooning of the foreskin with voiding.,38
" Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.",10
" Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.",38
 Right undescended testicle.  Orchiopexy & Herniorrhaphy.,38
" Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.",14
" Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.",38
" Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.",38
" A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.",5
  Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation.,38
 Primary low-transverse cesarean section.,38
" Left orchiopexy.  Ectopic left testis.   The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.",38
" Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine.  Nondiagnostic dobutamine stress test.   Normal nuclear myocardial perfusion scan.",33
 Patient scheduled for laparoscopic gastric bypass. ,5
 Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,38
" CT Brain: Suprasellar aneurysm, pre and post bleed.",33
" Headache, improved.  Intracranial aneurysm.",12
" Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.",24
 Upper gastrointestinal endoscopy.,38
" Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.",33
 Sports physical with normal growth and development.,29
" Pyogenic granuloma, left lateral thigh.   Excision of recurrent pyogenic granuloma.",38
 Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  ,27
 Cervical facet joint injection with contrast,28
 OssaTron extracorporeal shockwave therapy to right lateral epicondyle.  Right lateral epicondylitis.,27
" This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.",26
" Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.",38
" 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.",22
 Left flank pain and unable to urinate.,15
" Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.",5
" Thoracentesis, left.   Malignant pleural effusion, left, with dyspnea.",38
 MRI report Cervical Spine (Chiropractic Specific),22
" Total left knee replacement.  Degenerative arthritis of the left knee.  Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  ",38
" Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.",14
" Excision of sebaceous cyst, right lateral eyebrow.",38
" Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",38
 Spontaneous controlled sterile vaginal delivery performed without episiotomy.,24
" Open reduction and internal fixation (ORIF) of comminuted C2 fracture.  Posterior spinal instrumentation C1-C3, using Synthes system.  Posterior cervical fusion C1-C3.  Insertion of morselized allograft at C1to C3.",27
" Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.",39
 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.,33
" Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.",5
" Acute gastroenteritis, resolved.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.",10
 CT of the abdomen and pelvis without contrast.,21
 Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,39
" Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.",15
 Debridement left ischial ulcer.,38
 Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. ,10
" Intractable migraine with aura.  The patient is discharged home.  Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.",10
 Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,22
" Headache, improved.  Intracranial aneurysm.",22
 Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection.,33
" Carpal tunnel syndrome.  Open carpal tunnel release.  A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat. ",38
 Psychiatric History and Physical - Patient with major depression,32
" Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.",3
" Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.",38
 Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection.,38
 Barium enema - history of encopresis and constipation.,14
 Patient with fever of unknown origin.,15
 This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,5
" Pregnant female with nausea, vomiting, and diarrhea.  OB ultrasound less than 14 weeks, transvaginal.",24
 Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.,2
 Sample of Pulmonary Function Test,3
 A sample note on otitis media.,11
" The patient was originally hospitalized secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",3
" Subxiphoid pericardiotomy.  Symptomatic pericardial effusion.  The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.",38
" A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She is not on DMARD, but as she recently had a surgery followed by a probable infection.",34
 The patient was discharged by court as a voluntary drop by prosecution. ,32
" Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.",31
 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,23
"  Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.  ",16
" The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. ",39
 Return to work & Fit for duty evaluation.,5
 Bilateral breast MRI with & without IV contrast.,33
" EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, ",30
" Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.",21
" This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",21
" Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.",17
 Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome.,38
 Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,21
 Reduction of paraphimosis.,38
" Female with intermittent rectal bleeding, not associated with any weight loss.  The patient is chronically constipated.",14
 Trigger point injections with Botox.,28
 Diffuse Large B-cell Lymphoma,10
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.   Flexor tenotomy, bilateral third toes.",38
 Patient having foot pain.,35
 The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.,38
 MRI - Right temporal lobe astrocytoma.,33
 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,16
 Common description of colonoscopy,14
" Pancreatic and left adrenal lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. ",13
" Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.",29
 Insertion of Port-A-Cath via left subclavian vein using fluoroscopy in a patient with renal cell carcinoma.,38
 Patient referred for evaluation of her left temporal lobe epilepsy.,22
 Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,39
" Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.",5
" Coronary artery bypass grafting (CABG) x4.  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.",38
 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.,14
" Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  ",5
 Lower lid blepharoplasty.,38
 Full mouth dental rehabilitation in the operative room under general anesthesia.,7
" Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.",22
 Elevated cholesterol and is on medication to lower it.,35
" Fiberoptic nasolaryngoscopy.  Dysphagia with no signs of piriform sinus pooling or aspiration.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.",11
 Common CT C-Spine template,22
" 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, right common femoral artery angiogram runoff to the patient's right leg.",3
" A white female who presents for complete physical, Pap and breast exam.",5
" Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.",35
 Greater trochanteric bursal injection.,28
 Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis.,5
" Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",38
 A middle-aged male with increasing memory loss and history of Lyme disease.,22
 Feeling weak and shaky - Dyspnea on exertion and history of diabetes,5
" Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.  Right ventricular pacemaker lead placement and lead revision.",38
" Incision and drainage with extensive debridement, left shoulder.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).  Implantation of antibiotic beads, left shoulder.",27
" Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.",10
" This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.",38
" EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, ",22
" Esophagogastroduodenoscopy, patient with dysphagia.",38
 Bilateral scrotal orchiectomy,39
" The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.",5
 Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast.,14
 Lexiscan myoview stress study.  Chest discomfort.  Normal stress/rest cardiac perfusion with no indication of ischemia.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,33
 Closed reduction and placement of long-arm cast.,27
 Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,24
 A 51-year-old male with chest pain and history of coronary artery disease.,33
 Sample/template for a normal female multisystem exam,15
" Left inguinal herniorrhaphy, modified Bassini.  Left inguinal hernia, direct.",39
" First Pap smear, complaining of irregular periods.  - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.",24
" A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ",29
" Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.",12
 Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,34
 Template for History and Physical for a newborn.,29
 Transplant nephrectomy after rejection of renal transplant,21
" Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.",35
 Barium enema - history of encopresis and constipation.,33
" Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.",14
 Creation of right brachiocephalic arteriovenous fistula.,21
 The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,5
 Hardware removal in the left elbow.,27
  Plastic piece foreign body in the right main stem bronchus.  Rigid bronchoscopy with foreign body removal.,38
" Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.",38
" Excision of soft tissue mass, right foot.  The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.",31
" Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.",23
" Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.",3
 Conformal simulation with coplanar beams.  This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. ,16
 Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared.,27
" Severe back pain and sleepiness.  The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.",5
" Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",27
 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,27
 Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,27
 Fractional dilatation and curettage,38
" Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.",3
" Appendicitis, nonperforated.  Appendectomy.  A transverse right lower quadrant incision was made directly over the point of maximal tenderness. ",38
 Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.,27
 Ruptured appendicitis.,38
 Needle localization and left breast biopsy for left breast mass.,38
" Decompression of the ulnar nerve, left elbow.  Left cubital tunnel syndrome and ulnar nerve entrapment.",38
" The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",33
 Mother states he has been wheezing and coughing.,12
" A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis",5
 Consultation because of irregular periods and ovarian cyst.,24
" Excision of nasal tip basal carcinoma, previous positive biopsy.",38
" Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.",38
" 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.",39
" Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp.  Esophagogastroduodenoscopy with photos and antral biopsy.",14
 Urgent cardiac catheterization with coronary angiogram.,38
 Evaluation for bariatric surgery.,5
" Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.",38
 The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.,22
 Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage.  The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. ,11
" Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.",16
" Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.",38
 Blepharoplasty procedure,38
 Complex Regional Pain Syndrome Type I.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side and interpretation of Radiograph.,33
 Repair of ruptured globe with repositing of uveal tissue - Sample/Template.,38
 Decreased ability to perform daily living activity secondary to recent right hip surgery.,10
" Cervical cone biopsy, dilatation & curettage",24
 A sample note on serous otitis media,11
 Right hip osteoarthritis.  Total hip replacement on the right side.,27
" Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration.  Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.",39
" Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.",6
 A 3-year-old abrupt onset of cough and increased work of breathing.,10
" Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.",39
 A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.,5
 Chiropractic IME with old files review.  Detailed Thoracic Spine Examination.,4
 Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery.,33
 Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast.,14
 Intermittent rectal bleeding with abdominal pain.,14
" Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",38
 Right sacral alar notch and sacroiliac joint/posterior rami injections with/without fluoroscopy.,28
 Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis.,5
" Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.",3
" Lumbar muscle strain and chronic back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.",27
 Patient presents to the Emergency Department with complaint of a bleeding bump on his penis.,39
 Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms.,33
 Lexiscan Nuclear Myocardial Perfusion Scan.  Chest pain.  Patient unable to walk on a treadmill.  Nondiagnostic Lexiscan.  Normal nuclear myocardial perfusion scan.,33
" Direct inguinal hernia.  Rutkow direct inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  ",39
  Implantation of a single-chamber pacemaker.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,38
 A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast. ,3
 The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy.  She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy.  She is now referred to the thoracic surgery clinic for evaluation.,5
" The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",35
"  Primary low transverse cervical cesarean section.  Intrauterine pregnancy at 38 weeks and malpresentation.  A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.",24
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.",28
" Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.   Recurrent right inguinal hernia, as well as phimosis.",38
" Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.",38
" Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.",27
" Bilateral nasolacrimal probing.   Tearing, eyelash encrustation with probable tear duct obstruction bilateral.  Distal nasolacrimal duct stenosis with obstruction, left and right eye",38
" Counting calorie points, exercising pretty regularly, seems to be doing well",5
 Patient with stable expressive aphasia and decreased vision.,5
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",5
" A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. ",5
 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,22
 Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.,38
" Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.",8
" Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.",27
 Bilateral myringotomies and insertion of Shepard grommet draining tubes.,38
" A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The pain is located laterally as well as anteriorly into the groin. ",5
  Right carpal tunnel syndrome.  Right carpal tunnel release.,38
 Echocardiogram and Doppler,33
 HDR Brachytherapy,16
 The patient has been suffering from intractable back and leg pain.,5
 Right inguinal hernia.    Right direct inguinal hernia repair with PHS mesh system.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease. ,38
 The patient presents for a followup for history of erythema nodosum.,8
" A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. ",38
" Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, 
and congestive heart failure.",3
" This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.",13
 Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope.,23
" Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.",27
 Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.  ,29
" A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.  ",34
 Patient coughing up blood and with severe joint pain.,5
" Bilateral open mandible fracture, open left angle and open symphysis fracture.  Closed reduction of mandible fracture with MMF.",38
 Psychiatric Consultation of patient with major depression disorder.,32
" Lateral and plantar condylectomy, fifth left metatarsal.",38
 Newly diagnosed cholangiocarcinoma.  The patient is noted to have an increase in her liver function tests on routine blood work.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. ,5
" Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.",3
" A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.",32
" Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.",30
" Bassini inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ",38
" Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.",38
 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.,14
" Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",5
" Cystoscopy, cystocele repair, BioArc midurethral sling.",38
"  CT abdomen without contrast and pelvis without contrast, reconstruction.",14
" Removal of chest wall mass.  The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.",38
" The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.",30
" Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.",27
" A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.",10
" Total abdominal hysterectomy.  Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis.  On laparotomy, the uterus did have multiple pedunculated fibroids.",24
 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,33
" D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.",35
" Cerebrovascular accident (CVA).  The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. ",5
" He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ",39
" EGD and colonoscopy.  Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.",38
" Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).",33
" 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.",27
" Patient with abdominal pain, nausea, vomiting, fever, altered mental status.",15
" Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.",3
" Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.",14
 Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak.   Diffuse intestinal and mesenteric lymphangiectasia.  ,14
 Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.  Ventilator-dependent respiratory failure and laryngeal edema.,3
 Transvaginal ultrasound to evaluate pelvic pain.,33
 She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.,5
" Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.",10
" 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.",38
" Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.",33
 Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. ,3
 Placement of a subclavian single-lumen tunneled Hickman central venous catheter.  Surgeon-interpreted fluoroscopy.,3
 Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,11
" Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.",3
 Dental restorations and extractions.  Dental caries.  He has had multiple severe carious lesions that warrant multiple extractions at this time.,7
 Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. ,5
 A 3-month well-child check. ,29
" Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.
  ",27
 Common Excretory Urogram - IVP template,21
" 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.",38
 Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,35
 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.,30
" Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.",26
" Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.",27
 Patient with back and hip pain.,27
 MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old.,33
 Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared.,30
" Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder.  Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.",38
 Psychiatric Consultation of patient with altered mental status.,5
" Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.",23
" Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.",14
 Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.  ,5
" Trigger thumb release.  Right trigger thumb.  The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release). ",38
 Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. ,3
" Myoview nuclear stress study.  Angina, coronary artery disease.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.",33
 Placement of a Port-A-Cath under fluoroscopic guidancein a patient with anal cancer.,38
" MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.",35
" Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.",38
" Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.",27
" Still having diarrhea, decreased appetite.",14
 Patient status post lap band placement.,2
 Stroke in distribution of recurrent artery of Huebner (left),33
 The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,5
 Closed reduction and placement of long-arm cast.,38
 CCTA with Cardiac Function/Calcium Scoring,33
" An 85-year-old female with diarrhea, vomiting, and abdominal pain.",5
" Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis.  Carpal tunnel release and de Quervain's release.  A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis. ",38
" Ultrasound left lower extremity, duplex venous, due to swelling and to rule out DVT.  Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed.",33
" Morbid obesity.  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",14
" Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.",38
 Laparoscopic bilateral tubal ligation with Falope rings.,24
 Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,38
 Trigger thumb release.  A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  ,38
" A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. ",15
" A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.",15
 The patient had a syncopal episode last night.   She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,12
" Left carotid endarterectomy with endovascular patch angioplasty.  Critical left carotid stenosis.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.",38
 This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,12
 Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.  The patient is a 51-year-old female with back pain referring into the right leg.,28
 Probable Coumadin hypersensitivity.,5
 Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,15
" To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.",3
" 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. ",14
" Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.",24
" Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.",35
 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,33
 Likely molluscum contagiosum (genital warts) caused by HPV.  It is not clear where this came from but it is most likely sexually transmitted.,5
 Sample for Neuropsychological Evaluation,5
 Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,3
 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,26
" Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",15
" The patient underwent a scalp skin biopsy with pathology specimen obtained.   At the time of discharge, the patient had improved.",15
 Consultation for right shoulder pain.,28
 Consultation for jaw pain.,15
" Diagnostic laparoscopy and laparoscopic appendectomy.  Right lower quadrant abdominal pain, rule out acute appendicitis.",38
 Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.,3
 Small internal hemorrhoids and Ileal colonic anastomosis.,14
 Blood in urine - Transitional cell cancer of the bladder.,5
 Left shoulder injury.   A 41-year-old male presenting for initial evaluation of his left shoulder.,27
" Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.  Weil osteotomy with internal screw fixation, first right metatarsal.  Arthroplasty, second right PIP joint.",38
" MRI Brain, Carbon Monoxide poisoning.",33
 Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,39
 Left testicular swelling for one day.  Testicular Ultrasound.  Hypervascularity of the left epididymis compatible with left epididymitis.  Bilateral hydroceles.,33
 Direct laryngoscopy and bronchoscopy.,38
 Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast.,21
 Removal of the old right pressure equalizing tube.  Myringotomy with placement of a left pressure equalizing tube.,38
 Status post a high-speed motor vehicle accident in which patient was ejected from the vehicle.,12
 Esophagogastroduodenoscopy with photo.  Insertion of a percutaneous endoscopic gastrostomy tube.  Neuromuscular dysphagia.  Protein-calorie malnutrition.,38
" Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  Cataract, right eye.",38
 Discharge summary of a patient presenting with a large mass aborted through the cervix.,16
" Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",38
" Patient with wrist pain and swelling, status post injury.",33
" Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.",29
 Left little finger extensor tendon laceration.  Repair of left little extensor tendon.,38
 Initial visit for a 95-year-old gentleman with a Hospice diagnosis of CHF.,17
" Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.",21
" Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.",35
" Patient with hypertension, syncope, and spinal stenosis - for recheck.",3
" Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.",23
 An example normal physical exam,15
 Acute cholecystitis.  Laparoscopic cholecystectomy.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.,38
 Cystoscopy and removal of foreign objects from the urethra.,38
 Right-sided facial droop and right-sided weakness.  Recent cerebrovascular accident.  he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.,5
" Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.",3
" An 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. - Allergic rhinitis, fever history, sinusitis resolved, and teething.",5
 Likely molluscum contagiosum (genital warts) caused by HPV.  It is not clear where this came from but it is most likely sexually transmitted.,39
 Consultation for left foot pain.,5
" 11-year-old female.  History of congestion, possibly enlarged adenoids.  ",15
" Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.",3
" Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.",26
 Health maintenance exam for 1-year-old female.,29
" Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.",39
 Sample post dilation patient instructions.,25
 An example/template for a routine normal male physical exam.,15
" Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.",27
" Excision of dorsal wrist ganglion.  Made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.",38
 MRI - Right temporal lobe astrocytoma.,22
 Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,38
" 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.",38
 Dental prophylaxis under general anesthesia.,7
" New diagnosis of non-small cell lung cancer stage IV metastatic disease.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.",16
 The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,22
" Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.",11
 Pain.  Three views of the right ankle.  Three views of the right ankle are obtained.,31
" Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.",5
" Right total knee arthroplasty - Osteoarthritis, right knee.",38
 Anterior cranial vault reconstruction with fronto-orbital bar advancement.,23
" Screening colonoscopy.  Tiny polyps.   If adenomatous, repeat exam in five years.  ",14
 MRI C-spine: C4-5 Transverse Myelitis.,33
 Ultrasound OB - followup for fetal growth.,33
 Foul-smelling urine and stomach pain after meals.,39
 Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast.,33
 Echocardiogram with color flow and conventional Doppler interrogation.,3
" The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",15
" Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.",33
 Left axillary lymph node excisional biopsy.  Left axillary adenopathy.,38
 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,26
 Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration.,16
 Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,38
" A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The pain is located laterally as well as anteriorly into the groin. ",27
 The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.,22
 Left forearm arteriovenous fistula between cephalic vein and radial artery.,38
" Left buttock abscess, status post incision and drainage.   Recommended some local wound care",15
 Feeling weak and shaky - Dyspnea on exertion and history of diabetes,15
 Worrisome skin lesion.  A punch biopsy of the worrisome skin lesion was obtained.  Lesion was removed.,8
 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,23
 Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.,3
 A 14-year-old young lady is in the renal failure and in need of dialysis.,21
" Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.  Partial medial meniscectomy.  Partial chondroplasty of patella.  Lateral retinacular release.  Open medial plication as well of the right knee.",38
" To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.",5
" Cauterization of epistaxis, left nasal septum.  Fiberoptic nasal laryngoscopy.  Atrophic dry nasal mucosa.  Epistaxis.  Atrophic laryngeal changes secondary to inhaled steroid use.",11
 Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,5
" Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.",15
 Subcutaneous transposition of the right ulnar nerve.  Right carpal tunnel syndrome and right cubital tunnel syndrome.,38
" Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.",33
" Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.",38
" Total thyroidectomy.  The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter. ",38
" A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. ",5
" Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,",38
" Microscopic lumbar discectomy, left L5-S1.   Extruded herniated disc, left L5-S1.  Left S1 radiculopathy (acute). Morbid obesity.",27
 Sample progress note - Gen Med.,35
 Cardioversion.  Unsuccessful direct current cardioversion with permanent atrial fibrillation.,3
 The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.  ,11
" Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.",38
" Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.",5
" Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.",38
" Dilation and curettage (D&C) and hysteroscopy.  A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.",38
 Collar Tubes technique,11
" Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..",12
" A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ",11
" 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.",3
" Headaches, question of temporal arteritis.  Bilateral temporal artery biopsies.",22
" Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",38
" Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.  Weil osteotomy with internal screw fixation, first right metatarsal.  Arthroplasty, second right PIP joint.",27
" Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.",12
" MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.",33
 Iron deficiency anemia.  Diverticulosis in the sigmoid.,38
" Patient with suspected nasal obstruction, possible sleep apnea. ",11
 Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,38
 Myocardial perfusion imaging - patient had previous abnormal stress test.  Stress test with imaging for further classification of CAD and ischemia.,33
" Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.  The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.",5
 Patient has prostate cancer with metastatic disease to his bladder.  The patient has had problems with hematuria in the past.  The patient was encouraged to drink extra water and was given discharge instructions on hematuria.,5
 Right heart catheterization.   Refractory CHF to maximum medical therapy.,38
 Possible inflammatory bowel disease.  Polyp of the sigmoid colon..  Total colonoscopy with photography and polypectomy.,38
" Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.",25
 Scleral buckle opening under local anesthesia.,26
 Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. ,5
" Diagnostic arthroscopy exam under anesthesia, left shoulder.  Debridement of chondral injury, left shoulder.  Debridement, superior glenoid, left shoulder.  Arthrotomy.  Bankart lesion repair.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).",27
" A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. ",15
 Sample cardiology office visit note.,25
 Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,38
 GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia.,10
 External cephalic version.  A 39-week intrauterine pregnancy with complete breech presentation.,38
" Marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  she had a mammogram and ultrasound, which confirmed the right breast mass.",16
 Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,38
 Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.,3
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.",22
 MRI head without contrast.,22
 Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,38
" Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",35
 Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.,6
 Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. ,33
" Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.",38
 Nephrology Consultation - Patient with renal failure.,5
" Incompetent glottis.  Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.",11
" Trimalleolar ankle fracture and dislocation right ankle.  A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well.  Closed open reduction and internal fixation of right ankle.  ",27
" Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",35
 Heidenhain variant of Creutzfeldt-Jakob Disease (CJD),22
 Ventricular ectopy and coronary artery disease.   He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.,5
" The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",5
" Patient with a history of gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.",39
" Malignant mass of the left neck, squamous cell carcinoma.  Left neck mass biopsy and selective surgical neck dissection, left.",16
" The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.",12
 SPARC suburethral sling due to stress urinary incontinence.,39
" Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.",23
"  Tonsillectomy and adenoidectomy.  McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.",11
 Left Iliopsoas hematoma.  Gait difficulty.,5
 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.,22
 Left facial cellulitis and possible odontogenic abscess.  Attempted incision and drainage (I&D) of odontogenic abscess.,7
 Diagnostic laparoscopy and drainage of cyst.,33
 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,38
" A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.",5
 An example normal physical exam,5
" Right shoulder impingement syndrome, right suprascapular neuropathy.",18
 Repair of upper lid canalicular laceration - Sample/Template.,26
" A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.",38
" Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",3
 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,23
" Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.  The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",10
 Cerebral Angiogram - moyamoya disease.,33
 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,38
 Adenoidectomy procedure,38
" For evaluation of left-sided chest pain, 5 days post abdominal surgery.",15
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Akin bunionectomy, right toe with internal wire fixation.",27
" Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.",5
" Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.",23
 Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,3
 Sample progress note - Gen Med.,15
 Colonoscopy.  Change in bowel habits and rectal prolapse.  Normal colonic mucosa to the cecum.  ,38
  Left knee arthroscopy with lateral capsular release.,27
" The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.",5
 Encephalopathy related to normal-pressure hydrocephalus.,22
 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. ,33
" This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.",15
" The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",22
 A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.,33
 Psychosocial evaluation of kidney donor.  Questions - Answers,21
 Bilateral carotid ultrasound.,22
" Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.  Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.",38
 Open septorhinoplasty with placement of bilateral spreader grafts.  Bilateral lateral osteotomies.,38
 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.  ,23
 The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.  ,25
 Right breast excisional biopsy with needle-localization.  The patient is a 41-year-old female with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,38
 Diagnostic fiberoptic bronchoscopy.,3
" Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.",38
" Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.",23
 CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.,33
 Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,38
" Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.",24
 Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,38
 Stage IV necrotic sacral decubitus.  Debridement of stage IV necrotic sacral decubitus.,38
 Open reduction and internal fixation of left distal radius.,27
" Excision dorsal ganglion, right wrist.   The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. ",27
" Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.",27
 Right ear examination under anesthesia.  Right tympanic membrane perforation along with chronic otitis media.,11
" Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.  ",24
 CT Abdomen and Pelvis with contrast ,33
" 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.",15
" Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.",5
" Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.",14
" Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.",22
" Transurethral resection of the bladder tumor (TURBT), large.",38
 Consultation - an 87-year-old white female with weakness and a history of polymyositis.,34
 Phacoemulsification with posterior chamber intraocular lens insertion.,38
" Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.",38
" Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy.  Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.",38
 Dietary consultation for weight reduction secondary to diabetes.,5
" Patient was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. ",15
" Left heart catheterization, coronary angiography, left ventriculography.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.",3
 Quick note on tachypnea.,3
" Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. ",5
" EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",22
" 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, right common femoral artery angiogram runoff to the patient's right leg.",38
 The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,5
" Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.",27
 Patient with complaints of significant coughing and wheezing.,5
 Followup for polycythemia vera with secondary myelofibrosis.  JAK-2 positive myeloproliferative disorder.   He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.,35
 Repeat low transverse cesarean section and bilateral tubal ligation (BTL).  Intrauterine pregnancy at term with previous cesarean section.  Desires permanent sterilization.  Macrosomia.,38
" 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. ",38
" Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.  Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.",7
" Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.",15
" Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.",5
 History of right leg pain.  Leg pain is no longer present.,27
 CT REPORT - Soft Tissue Neck,33
 The patient is being discharged for continued hemodialysis and rehab.,10
" Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.",3
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",25
" Left below-the-knee amputation.  Dressing change, right foot.",27
 The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,35
 Patient with complaint of dark urine and generalized weakness.,15
 Laparoscopic right radical nephrectomy due to right renal mass.,38
" Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.",5
 Flexible Bronchoscopy (pediatric),29
" Excision of neuroma, third interspace, left foot.  Morton's neuroma, third interspace, left foot.",31
 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.,38
 Diagnostic laparoscopy and drainage of cyst.,24
 Laparoscopic tubal fulguration.,24
 Cardiac catheterization and coronary intervention report.,3
" Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.",38
" Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.",5
" Cervical epidural steroid injection, C5-6.  The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level. ",28
" Multiple contusions and abdominal pain, status post motor vehicle collision. ",12
" Patient with wrist pain and swelling, status post injury.",27
" A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. ",15
" Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.",15
 Tonsillectomy.   Tonsillitis.  McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. ,11
" Right and left heart catheterization, coronary angiography, left ventriculography.",38
 MRI demonstrated right contrast-enhancing temporal mass.,22
 Common CT Head template.,22
 Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.,7
 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,14
 CT of abdomen with and without contrast.  CT-guided needle placement biopsy.,33
 Tube Shunt  - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.,26
" Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve. ",38
 Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,3
" Patient admitted with abdominal pain, nausea and vomiting.",5
 Bilateral inguinal hernia.  Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,38
 A 47-year-old female with a posttraumatic AV in the right femoral head.,27
 Dietary consultation for diabetes during pregnancy.,35
 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,27
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",5
 Woman with a history of macular degeneration.  PDT therapy.  Some vision therapy.  Complete refractive work-up.,26
" Tilt table test.  Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.",3
 Endoscopic release of left transverse carpal ligament.,27
" Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.",5
 Fertile male with completed family.  Elective male sterilization via bilateral vasectomy.,38
" Left pleural effusion, parapneumonic, loculated.  Left chest tube placement.",38
 Prostate Brachytherapy - Prostate I-125 Implantation,33
 Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.,38
 Placement of cholecystostomy tube under ultrasound guidance.  Acute acalculous cholecystitis.,14
 Normal awake and drowsy (stage I sleep) EEG for patient's age.,22
" 9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.",29
 Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection.,22
" Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.",15
" 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 anesthetized with 1% Lidocaine.",38
" Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.",14
 Penile injury and continuous bleeding from a penile laceration.,39
 An example/template for a routine normal male physical exam.,25
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.",38
 Laparoscopic cholecystectomy with cholangiogram.  Acute gangrenous cholecystitis with cholelithiasis.  The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,33
 Inguinal herniorrhaphy.  A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ,39
 A 32-year-old male with shoulder pain.,27
" Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  ",35
" Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.",39
" Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.",14
" Pelvic tumor, cystocele, rectocele, and uterine fibroid.  Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. ",24
 Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,38
" A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.",5
 Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.,15
" Esophagogastroduodenoscopy, patient with dysphagia.",14
 Bladder instillation for chronic interstitial cystitis.,5
" Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.",10
" Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",38
" Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.",38
" Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.",5
 Ultrasound BPP - Advanced maternal age and hypertension.,33
 Psychiatric consultation for alcohol withdrawal and dependance.,5
 Left lower lobectomy.,38
 Psychiatric Consultation of patient with altered mental status.,32
 Examination under anesthesia and laparoscopic right orchiopexy.,38
"  Cataract, nuclear sclerotic, right eye.  Phacoemulsification with intraocular lens implantation, right eye.",38
 Esophagogastroduodenoscopy with photo.  Insertion of a percutaneous endoscopic gastrostomy tube.  Neuromuscular dysphagia.  Protein-calorie malnutrition.,14
" A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.",5
" Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation. ",35
" The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.",27
" Cervical spondylosis and kyphotic deformity.  She had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe. ",5
 MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,22
 MRI L-Spine - Bilateral lower extremity numbness,33
 Colonoscopy with random biopsies and culture.,14
 Total abdominal hysterectomy (TAH) with a uterosacral vault suspension.   Enlarged fibroid uterus and abnormal uterine bleeding. ,24
 Cystoscopy & Visual urethrotomy procedure,39
" 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.  ",14
" Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.",38
 Pediatric Gastroenterology - History of gagging.,14
" Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder.  Partial rotator cuff tear with impingement syndrome.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.",27
 Examination under anesthesia and laparoscopic right orchiopexy.,39
" Nuclear sclerotic cataract, right eye.  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.",38
" Chronic plantar fasciitis, right foot.  Open plantar fasciotomy, right foot.",27
 Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained.,22
" Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.",5
 Psychiatric Consultation of patient with anxiety.,5
 Autopsy - Ligature strangulation and craniocerebral injuries.,1
" Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward.",26
 This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night. ,11
" Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp.  Esophagogastroduodenoscopy with photos and antral biopsy.",38
 Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.,38
" Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy",3
" Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.",35
" Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.  Uncontrolled open angle glaucoma and conjunctival scarring, left eye.  ",26
" A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.",29
" Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.",24
" Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  ",38
 Bilateral myringotomies and insertion of Shepard grommet draining tubes.,11
" Head injury, anxiety, and hypertensive emergency.",12
 Right lower pole renal stone and possibly infected stent.  Cysto stent removal.,38
" Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well.  Chondromalacia of medial femoral condyle.   Medial meniscal tear, left knee.",38
 Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress.,5
 Right upper quadrant pain.  Nuclear medicine hepatobiliary scan.  Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,33
" Left flank pain, ureteral stone.",5
" Fiberoptic bronchoscopy with endobronchial biopsies.  A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.",38
" Visually significant nuclear sclerotic cataract, right eye.  Phacoemulsification with posterior chamber intraocular lens implantation, right eye.",26
 Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,15
 Consultation for an ASCUS Pap smear.,24
" This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. ",29
 Patient with complaints of significant coughing and wheezing.,3
 Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis. ,16
" Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.",38
" Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. ",14
" A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.",5
" Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy",33
 The patient needs refills on her Xanax,5
 Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. ,29
 Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.,3
 Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath.,15
 The patient was discharged by court as a voluntary drop by prosecution. ,10