description,medical_specialty " Bilateral Mammogram, (abnormal) additional views requested",33 " Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass.",3 This is a middle-aged female with two month history of low back pain and leg pain.,22 MRI Brain: Thrombus in torcula of venous sinuses.,33 Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. ,15 Direct right inguinal hernia. Marlex repair of right inguinal hernia.,39 " Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.",3 Patient with increased shortness of breath of one day duration.,15 Patient complains of chest pain - possible esophageal reflux,3 " Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,3 Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias,38 Work restrictions and disability evaluation ,4 Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,23 " Laparoscopic tubal sterilization, tubal coagulation. ",24 Common description of EGD.,38 " Complex regional pain syndrome, right upper extremity. Stellate ganglion block.",28 " 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. ",23 " 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. ",24 Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,3 Total colonoscopy with biopsy and snare polypectomy.,14 " Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.",3 A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. ,5 Common description of colonoscopy,14 CT Brain: Midbrain hemangioma,33 " Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",10 " Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 Bilateral Myringotomy with placement of PE tubes,11 " Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",24 Foul-smelling urine and stomach pain after meals.,14 Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. ,10 HCT for memory loss and for calcification of basal ganglia (globus pallidi).,33 Normal Circumcision,39 Primary low-transverse cesarean section.,24 Patient in ER with upper respiratory infection,15 Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.,38 MRI Cervical Spine without contrast.,33 " Pressure decubitus, right hip",15 Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. ,38 " Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 " Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.",3 Desires permanent sterilization. Laparoscopic bilateral tubal occlusion with Hulka clips.,38 " Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",16 Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,39 " The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. ",24 Sample of Pulmonary Function Test,3 " 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.",28 Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 Neurologic consultation and follow-up.,5 MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 " Right shoulder impingement syndrome, right suprascapular neuropathy.",22 " Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.",38 " Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm",3 Patient with a history of ischemic cardiac disease and hypercholesterolemia.,35 Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,11 " This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.",39 " Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration. Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.",38 " Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",27 " Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",29 Closure of gastrostomy placed due to feeding difficulties. ,14 Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,38 " 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.",25 " Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",35 " Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.,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.,38 " Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",23 " Patient with hypertension, dementia, and depression.",15 " The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",12 Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.,38 Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 " Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. ",10 " Cauterization of epistaxis, left nasal septum. Fiberoptic nasal laryngoscopy. Atrophic dry nasal mucosa. Epistaxis. Atrophic laryngeal changes secondary to inhaled steroid use.",38 Direct laryngoscopy and esophagoscopy with removal of foreign body,38 " A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. ",5 Patient with a history of ischemic cardiac disease and hypercholesterolemia.,3 " 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.",38 " Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",11 Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,38 Lysis of pelvic adhesions. The patient had an 8 cm left ovarian mass. The mass was palpable on physical examination and was tender. She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.,38 LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,24 Normal upper GI endoscopy.,14 Inguinal orchiopexy procedure.,38 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,39 " A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",23 " Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.",38 " Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.",27 Initial evaulation - neck and back pain.,5 Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,38 Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina.,38 Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. ,30 " Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.",38 Bilateral temporal artery biopsy. Rule out temporal arteritis.,38 " Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear. ",38 Multiple stent placements with Impella circulatory assist device.,38 The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,15 Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. ,38 Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.,10 Holter monitoring for syncope. Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. ,3 Tonsillectomy. Chronic tonsillitis.,38 " Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.",14 Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. ,3 MRI report Cervical Spine (Chiropractic Specific),27 Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. ,11 Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,39 " Negative for any nausea, vomiting, fevers, chills, or weight loss.",15 Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia.,38 " Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",38 " Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",35 Patient with intermittent episodes of severe nausea and abdominal pain.,15 " 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.",5 " Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",38 " Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 " Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.",38 1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.,5 Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.,38 Procedure note on Keller Bunionectomy,31 Diagnosis of benign rolandic epilepsy.,22 Endoscopic third ventriculostomy.,38 " Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",24 " 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. ",38 Left forearm arteriovenous fistula between cephalic vein and radial artery.,21 MRI right knee without gadolinium,27 " Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.",3 Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,15 " Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.",3 " 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.",5 Laparoscopic appendectomy. The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis.,38 Incision and drainage (I&D) of gluteal abscess. Removal of pigtail catheter. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,38 Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,30 " A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.",3 A 60-year-old female presents today for care of painful calluses and benign lesions.,35 " 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",15 External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.,24 " Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",38 " Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.",38 " A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.",5 " Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.",39 " Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",38 Patient with episode of lightheadedness and suddenly experienced vertigo.,22 " Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",27 Resting Myoview and adenosine Myoview SPECT,33 Sample progress note - Gen Med.,15 " Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 " Chief complaint of chest pain, previously diagnosed with hyperthyroidism.",5 Decreased ability to perform daily living activities secondary to right knee surgery.,10 " 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.",3 " Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",15 Patient with palpitations and rcent worsening of chronic chest discomfort.,5 " The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",32 Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. ,14 Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,16 " Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy. ",7 " New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ",27 Pain management for post-laminectomy low back syndrome and radiculopathy. ,5 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.,21 " The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",24 " The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ",32 A 65-year-old man with chronic prostatitis returns for recheck.,35 The patient comes in today because of feeling lightheaded and difficulty keeping his balance.,22 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.,15 Axial images through the cervical spine with coronal and sagittal reconstructions.,27 " Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.",21 " Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.",38 Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 Occupational medicine consult with questions-answers and records review.,18 Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,16 Common description of EGD,38 Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. ,5 " Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.",35 Overactive bladder with microscopic hematuria.,39 " Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",33 " Followup diabetes mellitus, type 1.",35 " The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",35 Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. ,11 Patient with morbid obesity.,5 " 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.",5 " 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.",12 " Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress. ",15 Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 " 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. ",27 Orchiopexy & inguinal herniorrhaphy.,38 " Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",16 The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time. ,27 " Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",38 " Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",38 " Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",16 " The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.",3 Whole body radionuclide bone scan due to prostate cancer.,33 " A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.",5 Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,3 " Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant. Chronic pelvic pain, probably secondary to endometriosis.",38 " Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",33 " Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.",27 " Nausea, vomiting, diarrhea, and fever.",5 Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.,5 " Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 " The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.",15 " Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.",38 " Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",23 Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. ,38 " 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. ",22 " Placement of Scott cannula, right lateral ventricle",38 Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,38 " Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",10 Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.,3 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,38 Esophagogastroduodenoscopy performed in the emergency department.,14 " Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 " Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.",14 " Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis. ",14 " Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. ",27 " This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.",21 " Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",38 ,37 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,23 " A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. ",14 " Open reduction, nasal fracture with nasal septoplasty.",11 Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 " Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.",38 Patient dropped a weight on the dorsal aspects of his feet.,31 " Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.",14 Most commonly used phrases in physical exam.,25 Dobutamine stress test for atrial fibrillation.,3 H&P for a female with Angina pectoris.,3 " 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.",38 Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.,27 Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,38 " Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",22 " Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",3 A 16-year-old male with Q-fever endocarditis.,3 " Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 " Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",24 " Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",38 " Left thyroid mass. Left total thyroid lumpectomy. The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",38 " He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.",15 " Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",38 " Emergent subxiphoid pericardial window, transesophageal echocardiogram.",3 Bilateral renal ultrasound.,33 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,23 " Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. ",37 " Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ",16 Brain CT and MRI - suprasellar mass (pituitary adenoma),33 Patient with episode of lightheadedness and suddenly experienced vertigo.,5 Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,35 Insertion of central venous line and arterial line and transesophageal echocardiography probe.,3 The patient is admitted with a diagnosis of acute on chronic renal insufficiency.,21 Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.,38 Patient with dysphagia.,38 " Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.",15 " Anxiety, alcohol abuse, and chest pain. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. ",5 " Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 " History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.",5 " Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.",33 Bilateral scrotal orchiectomy,38 " Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",23 Patient in ER due to colostomy failure - bowel obstruction.,14 A 2-month-old female with 1-week history of congestion and fever x2 days.,29 Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. ,38 " Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.",38 " Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.",27 " Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.",5 A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,35 " Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",3 " Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",38 " Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",27 Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 " Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.",5 CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,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.,33 Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,16 Upper endoscopy with foreign body removal (Penny in proximal esophagus).,14 " Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ",35 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,5 " Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.",38 " Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",35 Left elbow manipulation and hardware removal of left elbow.,27 " Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",5 4-day-old with hyperbilirubinemia and heart murmur.,12 Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 Bilateral renal ultrasound.,21 " Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",24 " Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.",38 " Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ",38 " 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. ",22 Sample Radiology report of knee (growth arrest lines).,33 Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.,38 " Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus. ",10 Patient in ER with upper respiratory infection,12 An example/template for a routine normal female physical exam.,5 Chiropractic IME with answers to questions from Insurance Company.,20 " Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.",38 " Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",35 " 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.",24 Left temporal craniotomy and removal of brain tumor.,22 Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. ,38 MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,33 " 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.",27 Esophagogastroduodenoscopy and colonoscopy with polypectomy,14 Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,22 " Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 " History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.",33 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,23 " Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.",38 " Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot.",38 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,12 Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. ,39 Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,38 Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,38 Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 " Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.",26 " Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",14 " Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. ",24 " Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.",38 Psychiatric evaluation for major depression without psychotic features.,32 A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,24 Postpartum tubal ligation and removal of upper abdominal skin wall mass.,38 Normal upper GI endoscopy.,38 " Pregnant female with nausea, vomiting, and diarrhea. OB ultrasound less than 14 weeks, transvaginal.",33 " Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. ",3 Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer.,38 Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,39 " 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.",38 " The patient died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 " Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.",27 The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.,5 " Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",38 " Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",26 Sample for Neuropsychological Evaluation,32 " 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.",15 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,38 " Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.",27 " Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",27 MRI Brain & T-spine - Demyelinating disease.,33 Neurologic consultation was requested to evaluate her seizure medication and lethargy.,5 " Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",35 Evaluation for chronic pain program,27 Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,38 Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,14 " Sample normal ear, nose, mouth, and throat exam.",5 Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.,27 Carotid artery angiograms.,33 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,23 " Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",35 " He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.",3 " She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.",14 Short-term memory loss (probable situational) and anxiety stress issues.,5 " Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",26 An example/template for a routine normal male physical exam.,25 A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,10 " Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, ",38 " Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.",15 " Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.",38 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.,38 " 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.",22 " An 85-year-old female with diarrhea, vomiting, and abdominal pain.",15 Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.,22 Routine colorectal cancer screening. He occasionally gets some loose stools. ,16 " The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,38 Laparoscopic supracervical hysterectomy. A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.,38 " Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain",35 A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.,22 Right basilic vein transposition. End-stage renal disease with need for a long-term hemodialysis access. Excellent flow through fistula following the procedure.,38 Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,38 Appendicitis. Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants.,38 " Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",38 The patient with a recent change in bowel function and hematochezia.,14 Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region and adjacent tissue transfer closure of the left supraclavicular grafting site,38 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. ,29 MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.,3 Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,32 " A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.",5 " 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.",29 " Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 Patient with a three-day history of emesis and a four-day history of diarrhea,15 MRI C-spine: C4-5 Transverse Myelitis.,27 Ultrasound-Guided Paracentesis for Ascites,33 Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. ,33 Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.,38 " Cervical spondylosis. Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.",28 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.,26 Right pontine pyramidal tract infarct.,33 " A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. ",10 " Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.",3 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,38 " Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. ",22 " A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.",38 " Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.",15 " Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",23 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.,23 Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 Progressive loss of color vision OD.,5 Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.,14 " 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. ",30 " Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.",14 " Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.",3 " Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot.",38 " Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.",33 " Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.",5 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,27 The patient is brought in by an assistant with some of his food diary sheets.,5 Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,38 " 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. ",10 Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,11 Direct right inguinal hernia. Marlex repair of right inguinal hernia.,38 " A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.",12 " 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..",7 " Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.",14 " Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.",38 " Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear. ",11 " Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",29 Patient with immune thrombocytopenia,16 Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva.,38 Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,11 " Microscopic lumbar discectomy, left L5-S1. Extruded herniated disc, left L5-S1. Left S1 radiculopathy (acute). Morbid obesity.",38 " Normal physical exam template. Well developed, well nourished, in no acute distress.",5 Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,5 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,38 " Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. ",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.",3 " Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.",27 " Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",24 Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,38 " Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management",15 Patient referred for evaluation of her left temporal lobe epilepsy.,5 Upper endoscopy with removal of food impaction.,38 Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,38 " Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",38 Decreased ability to perform daily living activity secondary to recent right hip surgery.,27 Consultation for an ASCUS Pap smear.,5 Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. ,38 " Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis. ",38 Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. ,5 " Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.",5 Scleral buckle opening under local anesthesia.,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.",29 Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.,3 " CT abdomen without contrast and pelvis without contrast, reconstruction.",21 " 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.",5 CT Abdomen and Pelvis with contrast ,21 " Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.",38 Right hip osteoarthritis. Total hip replacement on the right side.,38 " Right and left heart catheterization, coronary angiography, left ventriculography.",3 " Patient with atrial fibrillation with slow ventricular response, partially due to medications.",5 Resting Myoview and adenosine Myoview SPECT,3 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.,32 A 47-year-old female with a posttraumatic AV in the right femoral head.,10 A 65-year-old man with chronic prostatitis returns for recheck.,39 " Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).",5 " Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.",27 " 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.",23 " Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",26 " Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",5 " 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.",16 Circumcision procedure in a baby,38 " Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.",38 Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap. Adenocarcinoma of the prostate.,38 Laparoscopic cholecystectomy with cholangiogram.,38 " Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.",14 Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,5 " The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",39 Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,38 " Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 " Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.",27 " Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",10 " Still having diarrhea, decreased appetite.",35 This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,22 Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,38 AP abdomen and ultrasound of kidney.,21 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.,38 Most commonly used phrases in physical exam.,5 The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,5 " 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.",5 " The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.",15 Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.,27 1-month-old for a healthy checkup - Well child check,29 " C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",38 " Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",38 Patient with a long history of depression and attention deficits.,32 " A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ",5 Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,3 " Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.",38 " 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. ",12 " A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",38 " Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",24 MRI of lumbar spine without contrast to evaluate chronic back pain.,27 Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.,38 " Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.",14 Ultrasound Abdomen - elevated liver function tests.,33 2-D Echocardiogram,33 A 34-year old female with no fetal heart motion noted on office scan.,24 " 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.",27 Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 This patient was seen in clinic for a school physical.,5 Encephalopathy related to normal-pressure hydrocephalus.,5 " Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",38 " Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 Spermatocelectomy and orchidopexy,39 " Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.",10 " Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.",27 " This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.",5 " Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",35 This patient has reoccurring ingrown infected toenails.,31 Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,21 Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.,38 A sample note on Conjunctivitis (Pink Eye).,26 " A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.",35 A sample note on Cataract,26 " Incompetent glottis. Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.",38 The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,37 " Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",10 " Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",26 " Nuclear medicine tumor localization, whole body - status post subtotal thyroidectomy for thyroid carcinoma.",33 " Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.",27 " Right knee total arthroplasty. Degenerative osteoarthritis, right knee.",38 " A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.",32 Common CT Head template.,33 Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration.,38 " Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. ",27 Laparoscopic cholecystectomy.,38 Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 CT chest with contrast.,33 " A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.",30 Coronary Artery CTA with Calcium Scoring and Cardiac Function,3 " Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.",35 " Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.",28 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,28 An example/template for a routine normal male physical exam.,25 The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,5 " Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",35 Consult for prostate cancer,5 Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,39 Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,16 " Total Abdominal Hysterectomy (TAH). An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. ",38 The patient states that he feels sick and weak.,35 " A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ",30 " 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.",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.",27 " Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",39 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. ,35 " Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. ",38 Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.,27 Coronary Artery CTA with Calcium Scoring and Cardiac Function,33 The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,32 " Patient with chest pains, CAD, and cardiomyopathy.",33 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,38 " Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.,38 " Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.",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.",15 " Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",5 Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,14 Pain management for post-laminectomy low back syndrome and radiculopathy. ,4 " Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.",38 " Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.",15 " Hypomastia. Patient wants breast augmentation and liposuction of her abdomen, ",6 " CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.",22 CT scan of the abdomen and pelvis without and with intravenous contrast.,33 Patient with a diagnosis of stroke.,5 Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 A middle-aged male with increasing memory loss and history of Lyme disease.,33 " Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",27 " Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.",38 " Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.",33 SPARC suburethral sling due to stress urinary incontinence.,38 " Creation of AV fistula, left wrist in the anatomic snuffbox.",21 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. ,22 MRI C-spine: C4-5 Transverse Myelitis.,22 " 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",5 " Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.",38 " Right open carpal tunnel release and cortisone injection, left carpal tunnel.",27 Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,5 Right carpal tunnel release.,27 Injection of Morton's neuroma.,28 Itchy red rash on feet - Tinea Pedis,5 " Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",10 Patient in with mom for possible ear infection.,15 This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,33 " Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.",38 " History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.",5 Chiropractic IME with answers to questions from Insurance Company.,4 Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.,14 Psychiatric History and Physical - Patient with schizoaffective disorder.,5 " Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,14 MRI left shoulder.,27 Left third digit numbness and wrist pain.,27 Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.,27 " Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.",27 Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,38 A white female presents for exam and Pap.,24 " Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.",3 Transesophageal echocardiogram and direct current cardioversion.,3 " Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.",3 " Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot.",27 Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.,38 A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 " Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.",24 Consult and Spinal fluid evaluation in a 15-day-old,29 An example/template for a routine normal male physical exam.,15 Collar Tubes technique,38 An example/template for meatotomy.,38 " Phacoemulsification of cataract and posterior chamber lens implant, right eye.",26 " Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.",38 Nephrology office visit for followup of microscopic hematuria.,21 " Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",22 Iron deficiency anemia. Diverticulosis in the sigmoid.,14 " Ultrasound abdomen, complete",33 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.,14 " Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.",38 " Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",38 Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,24 Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,38 A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,5 " Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.",38 Excision of penile skin bridges about 2 cm in size.,39 Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. ,24 Followup on chronic kidney disease.,21 " Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,21 " This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.",5 " Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",10 A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. ,5 " Nuclear sclerotic cataract, right eye. Kelman phacoemulsification with posterior chamber intraocular lens, right eye.",26 " Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.",15 " Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.",26 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.,38 " Right inguinal hernia. Right inguinal hernia repair. The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",39 Dietary consultation for carbohydrate counting for type I diabetes.,5 " Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.",38 " Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.",38 Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. ,27 " Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.",3 Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,25 " Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",38 Incision and drainage (I&D) of buttock abscess. ,8 " 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.",38 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.,27 " Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.",10 Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,33 " Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.",3 Thallium stress test for chest pain.,33 Esophagogastroduodenoscopy performed in the emergency department.,38 " Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",38 " Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.",39 Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,38 MRI T-spine and CXR - Aortic Dissection.,33 " History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy.",38 " Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",38 Cystoscopy & Visual urethrotomy procedure,38 " Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.",3 " Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.",3 Hardware removal in the left elbow.,38 " Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.",5 " 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. ",22 Antibiotic management for a right foot ulcer and possible osteomyelitis.,5 Pain management for post-laminectomy low back syndrome and radiculopathy. ,27 " Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",27 " Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ",38 " Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",10 Transforaminal epidural steroid block with fluoroscopy.,28 Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,35 Open reduction and internal fixation of left tibia.,27 A sample note on bilateral myringotomy tubes,11 Patient with complaint of dark urine and generalized weakness.,5 Patient with a history of right upper pons and right cerebral peduncle infarction.,22 Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative.,33 " Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",38 " Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",21 Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 " Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.",12 " Patient with multiple problems, main one is chest pain at night.",15 " Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 " Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.",16 Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.,27 " 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.",27 The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.,39 Right orchiopexy and right inguinal hernia repair.,39 " Fiberoptic nasolaryngoscopy. Dysphagia with no signs of piriform sinus pooling or aspiration. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.",38 Laparoscopic right salpingooophorectomy. Right pelvic pain and ovarian mass. Right ovarian cyst with ovarian torsion.,38 " 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.",3 " Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.",38 Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,24 She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,15 Complaint of mood swings and tearfulness.,15 Bronchoscopy for hypoxia and increasing pulmonary secretions,3 Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.,14 Frontal and lateral views of the hip and pelvis.,29 " Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.",27 " Follow up consultation, second opinion, foreskin.",39 " 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.",31 " Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. ",11 Patient with history of adenomas and irregular bowel habits.,14 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.,38 " Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.",39 Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,29 Left third digit numbness and wrist pain.,33 " 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.",38 " Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. ",15 Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,5 Sample female review of systems.,15 Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,38 Left retrosigmoid craniotomy and excision of acoustic neuroma.,23 Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,5 " Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",27 " 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. ",27 " Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",38 Ligament reconstruction and tendon interposition arthroplasty of right wrist.,27 " This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ",22 " Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.",38 Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,27 MRI left knee without contrast.,27 Holter Monitor Report,3 " Counting calorie points, exercising pretty regularly, seems to be doing well",35 " Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 " Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",15 Right and Left carotid ultrasound ,33 " Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication. ",38 " Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis.",5 " Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",27 Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.,14 " MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.",27 " Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",15 " Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.",38 Follow up update on patient with left carotid angioplasty and stent placement.,20 Template for History and Physical for a newborn.,5 Knee injection,28 Dietary consultation for diabetes during pregnancy.,5 " Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",5 OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.,33 Bilateral carotid ultrasound to evaluate pain.,33 Colonoscopy in a patient with prior history of anemia and abdominal bloating.,38 Vitrectomy under local anesthesia.,26 Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.,5 A 12-year-old with discoid lupus on the control with optimal regimen.,5 " Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 Acute appendicitis and 29-week pregnancy. Appendectomy.,38 Lumbar epidural steroid injection for lumbar radiculopathy.,28 " Lateral and plantar condylectomy, fifth left metatarsal.",27 " Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. ",6 Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,38 " Patient had some cold symptoms, was treated as bronchitis with antibiotics.",10 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.,14 Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,38 " Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.",15 " Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. ",2 " Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.",38 Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.,33 " Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",38 Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound.,38 " 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. ",27 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.,3 Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.,3 Epigastric herniorrhaphy. Epigastric hernia.,14 Tracheotomy for patient with respiratory failure.,3 Initial evaulation - neck and back pain.,27 " A white female who presents for complete physical, Pap and breast exam.",24 " Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",3 " Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 A two week well-child check.,29 Sample/template for a normal female multisystem exam,5 Patient with fever of unknown origin.,10 Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,38 " The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 Left shoulder pain. Evaluate for rotator cuff tear.,27 " Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.",38 " Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.",15 Duplex ultrasound of legs,33 " 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.",23 " Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",21 Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins.,3 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,22 " Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.",3 " This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ",5 " Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass.",38 Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 " Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",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.",5 Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker.,3 Vaginal discharge with a foul odor.,24 " He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.",35 " The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",11 " Laparoscopic tubal sterilization, tubal coagulation. ",38 " Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.",14 " 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. ",29 " 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.",38 " Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.",38 " Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.",14 Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.,24 " Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. ",35 " Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.",14 Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,38 " Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment.",27 The patient with atypical type right arm discomfort and neck discomfort.,38 " Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. ",38 Thoracentesis. Left pleural effusion. Left hemothorax.,38 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,27 " Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",38 CCTA with Cardiac Function/Calcium Scoring,3 Flexible Bronchoscopy (pediatric),3 Consultation for FCR tendinitis,27 " 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.",27 Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. ,5 " Colonoscopy - Diarrhea, suspected irritable bowel",14 Dysarthria. Probable brainstem glioma.,5 " Patient with abdominal pain, nausea, vomiting, fever, altered mental status.",5 " MRI of the Cervical, Thoracic, and Lumbar Spine",33 " Patient had some cold symptoms, was treated as bronchitis with antibiotics.",3 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. ,35 " Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid. Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.",38 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,22 " 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.",24 " Exam under anesthesia with uterine suction curettage. A 10-1/2 week pregnancy, spontaneous, incomplete abortion.",38 " Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",10 " This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. ",35 " Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.",38 1-year well child check.,5 Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.,3 " Plantar fascitis, left foot. Partial plantar fasciotomy.",31 " Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",38 Psychiatric Consultation of patient with anxiety.,32 Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.,27 Laparoscopic appendectomy. Acute appendicitis.,38 " This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. ",14 " Selective coronary angiography, coronary angioplasty. Acute non-ST-elevation MI.",3 " Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 Psychosocial Evaluation of patient before kidney transplant.,32 Right pleural effusion and suspected malignant mesothelioma.,3 " 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.",14 Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.,27 Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.,38 Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome.,32 Cardiology office visit sample note.,25 Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. ,24 Left retrosigmoid craniotomy and excision of acoustic neuroma.,22 " The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",24 " Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. ",5 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.,3 " Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",11 Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.,27 Burr hole and insertion of external ventricular drain catheter.,23 " Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.",14 " This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",12 Ophthalmology followup visit note.,26 Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.,14 " Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",38 " 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. ",5 " 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.",27 " Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",35 " First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.,22 " Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",38 Patient coughing up blood and with severe joint pain.,15 Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax.,16 " Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress. ",5 " Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",39 " Congestion, tactile temperature.",15 Right radical nephrectomy and assisted laparoscopic approach.,21 " Adenotonsillectomy, primary, patient under age 12.",38 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,22 " 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.",16 Bilateral open Achilles lengthening with placement of short leg walking cast.,27 " The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. ",8 " Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.",11 " General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, ",15 " Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",16 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.,12 " 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. ",33 " Patient with multiple problems, main one is chest pain at night.",5 A 23-year-old white female presents with complaint of allergies.,0 Pain and swelling in the right foot.,33 Complete eye examination - Normal eye and vision exam.,5 " A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.",3 Patient is here to discuss possible open lung biopsy.,35 Standard Laparoscopic Cholecystectomy Operative Note.,14 " Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.",5 Left little finger extensor tendon laceration. Repair of left little extensor tendon.,27 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,27 " Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.",27 " Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).",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.",3 Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed,38 The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,16 " For evaluation of left-sided chest pain, 5 days post abdominal surgery.",5 Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,38 " School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",32 General Medicine SOAP note.,15 " Skull, complete, five images.",33 " Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",16 " Re-excision of squamous cell carcinoma site, right hand.",38 MRI left knee.,33 A 51-year-old male with chest pain and history of coronary artery disease.,3 Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,32 Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm.,5 " Acute lymphocytic leukemia in remission, removal of venous port.",38 Neurologic consultation was requested to assess and assist with seizure medication.,5 Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.,5 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 " Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ",14 " Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow.",27 A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,32 Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,23 Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. ,14 " Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.",27 " Melena and solitary erosion over a fold at the GE junction, gastric side.",38 Consultation for wrist pain.,5 Flexible Sigmoidoscopy.,14 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. ,38 " Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",38 " Arthroscopy with arthroscopic subacromial decompression of the left shoulder. Impingement syndrome, left shoulder. Rule out superior labrum anterior and posterior lesion, left shoulder.",38 " 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. ",27 " Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",10 " Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.",39 " Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.",3 Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,38 " Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",38 " Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",5 The patient is being referred for evaluation of diabetic retinopathy.,20 A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.,15 " Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.",38 A 23-year-old white female presents with complaint of allergies.,35 Patient with back and hip pain.,5 " 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.",5 Pulmonary function test. Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy.,3 Left elbow manipulation and hardware removal of left elbow.,38 " Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. ",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, ",33 " Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.",39 MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old.,22 Work restrictions and disability evaluation ,18 Evaluation for bariatric surgery.,2 Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound.,3 A 27-year-old female with a size and date discrepancy.,33 " Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 " 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.",27 Inguinal hernia hydrocele repair.,38 " Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",12 a pleasant 62-year-old male with cerebral palsy,10 " Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.",5 A 3-year-old abrupt onset of cough and increased work of breathing.,29 Arterial imaging of bilateral lower extremities. ,33 " Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",25 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.,15 Colonoscopy in a patient with prior history of anemia and abdominal bloating.,14 " Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.",38 " The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. ",15 A 17-year-old male with oligoarticular arthritis of his right knee.,5 The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. ,5 Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.,5 Endoscopic proximal shunt revision.,38 " Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.",38 " 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.",8 Transesophageal echocardiogram and direct current cardioversion.,33 " Chest, Single view post OP for ASD (Atrial Septal Defect).",3 " 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.",38 " Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",39 " Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",35 Common description of EGD.,14 Left flank pain and unable to urinate.,5 Patient discharged after laparoscopic Roux-en-Y gastric bypass.,10 " Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.",3 A 60-year-old female presents today for care of painful calluses and benign lesions.,31 " Left flank pain, ureteral stone.",39 " Cystoscopy, cystocele repair, BioArc midurethral sling.",39 " 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.",22 " Thoracentesis, left. Malignant pleural effusion, left, with dyspnea.",3 " Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",21 " Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.",24 " 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.",31 A 19-year-old right-handed male injured in a motor vehicle accident.,27 Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,24 " Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.",26 Repair of upper lid canalicular laceration - Sample/Template.,38 Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,24 Normal vasectomy,39 Patient status post lap band placement.,38 Pain. Three views of the right ankle. Three views of the right ankle are obtained.,27 " 5-month recheck on type II diabetes mellitus, as well as hypertension.",15 " 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.",27 " Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 Patient with right ankle pain.,33 " Phacoemulsification of cataract, extraocular lens implant in left eye.",38 Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,38 Occupational medicine consult with questions-answers.,18 " EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,38 " Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",16 " 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.",21 Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation.,38 " Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. ",38 Laparoscopic left inguinal hernia repair.,38 Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 " Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.",38 " Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",24 H&P for a female with Angina pectoris.,5 " Head injury, anxiety, and hypertensive emergency.",29 " The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 " Acute appendicitis, gangrenous. Appendectomy.",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.",5 " Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.",28 " 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.",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. ,14 Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation.,29 Patient with immune thrombocytopenia,35 Psychosocial Evaluation of patient before kidney transplant.,21 Sample cardiology office visit note.,3 " L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.",38 Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,10 Noncontrast CT head due to seizure disorder.,22 " Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",22 Dietary consultation for gestational diabetes.,9 " Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",12 Decreased ability to perform daily living activities secondary to right knee surgery.,27 " Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.",21 Tonsillectomy and adenoidectomy. Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,38 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. ,23 " Right shoulder impingement syndrome, right suprascapular neuropathy.",5 Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,27 Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus.,14 " 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.",10 " Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",11 " Excision of nasal tip basal carcinoma, previous positive biopsy.",16 Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak. Diffuse intestinal and mesenteric lymphangiectasia. ,38 " Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.",3 Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 " Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",23 Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.,33 History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.,5 " This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. ",5 Pediatric Gastroenterology - Rectal Bleeding Consult.,29 The patient underwent a total vaginal hysterectomy.,10 " 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.",21 MRI Cervical Spine without contrast.,22 " Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. ",39 " Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.",24 " The thoracic spine was examined in the AP, lateral and swimmer's projections.",27 Tube Shunt - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.,38 Spermatocelectomy and orchidopexy,38 " Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.",28 Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization.,3 " Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",11 Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,38 " Aortoiliac occlusive disease. Aortobifemoral bypass. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.",38 " Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",10 " Pain and swelling in the right foot, peroneal tendon tear.",27 " Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. ",5 Dietary consultation for gestational diabetes.,5 " Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.",5 " 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. ",5 Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,38 Worrisome skin lesion. A punch biopsy of the worrisome skin lesion was obtained. Lesion was removed.,38 Possible cerebrovascular accident. The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. ,22 Headache and diplopia.,5 " EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",22 Fifth disease with sinusitis,35 Diagnostic cerebral angiogram and transcatheter infusion of papaverine,33 Small internal hemorrhoids and Ileal colonic anastomosis.,38 " Essential thrombocytosis. He underwent a bone marrow biopsy, which showed essential thrombocytosis. His CBC has been very stable. ",35 " Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",24 Stage I and II neuromodulator.,39 Is it BNP or BMP?,19 Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.,3 Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 Penile injury and continuous bleeding from a penile laceration.,12 " There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. ",25 Chest tube talc pleurodesis of the right chest.,38 " Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2",5 " A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",29 Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,5 " Hypomastia. Patient wants breast augmentation and liposuction of her abdomen, ",5 " Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 MRI of lumbar spine without contrast to evaluate chronic back pain.,33 " Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency",15 Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.,38 " Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",38 Cystoscopy. Transurethral resection of the prostate.,39 General Medicine SOAP note.,35 Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,11 " Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,38 Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,12 Psychiatric Consultation of patient with dementia.,32 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,23 Right pleural effusion and suspected malignant mesothelioma.,38 Occupational medicine consult with questions-answers and records review.,18 " 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. ",27 " Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.",38 Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. ,11 " Open reduction, nasal fracture with nasal septoplasty.",38 " Pain and swelling in the right foot, peroneal tendon tear.",31 " Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.",3 " Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",5 Patient in ER due to colostomy failure - bowel obstruction.,12 MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,33 " Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.",38 A 3-year-old abrupt onset of cough and increased work of breathing.,3 Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.,38 Sample/template for a normal male multisystem exam.,5 Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,3 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,33 A female with unknown gestational age who presents to the ED after a suicide attempt.,5 " A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ",22 " Cystoscopy, cryosurgical ablation of the prostate.",39 Nephrology office visit for followup of CKD.,25 MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,22 Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. ,38 " Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",24 An example/template for a routine normal male physical exam.,5 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. ,38 " 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.",38 Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,24 " Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",27 " 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..",5 Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.,27 Consult for laparoscopic gastric bypass.,5 Cystoscopy. Transurethral resection of the prostate.,38 " Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.",3 Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. ,3 CT Brain: Subarachnoid hemorrhage.,33 Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,3 " The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.",22 Fractional dilatation and curettage,24 ,22 Common description of colonoscopy,38 Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. ,15 Ultrasound OB - followup for fetal growth.,24 Left distal medial hamstring release.,27 " Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.",3 " Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.",38 Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,25 Difficulty with both distance vision and with fine print at near.,26 " Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.",10 Fifth disease with sinusitis,15 Right upper quadrant pain. Nuclear medicine hepatobiliary scan. Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,14 Cardiology office visit sample note.,3 " EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 " Follow up consultation, second opinion, foreskin.",35 " Total abdominal hysterectomy. Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis. On laparotomy, the uterus did have multiple pedunculated fibroids.",38 " Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. ",24 " Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.",38 " Patient admitted with abdominal pain, nausea and vomiting.",15 " Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",23 Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,38 " EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.",14 2-D M-Mode. Doppler. ,33 Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,3 The patient was running and twisted her right ankle - right ankle sprain.,5 " DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,",38 " Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.",27 " Tonsillectomy and adenoidectomy. McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.",38 Arthroscopic procedure of the knee.,38 Follow up update on patient with left carotid angioplasty and stent placement.,3 " Fever, otitis media, and possible sepsis.",29 Patient complains of chest pain - possible esophageal reflux,12 " Brachytherapy, iodine-125 seed implantation, and cystoscopy.",38 Endovascular Brachytherapy (EBT),3 " 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.",14 An example/template for a routine normal male physical exam.,5 " 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.",12 An example of a physical exam,25 " Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy",21 " Skull, complete, five images.",29 LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,38 " Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. Cataract, right eye.",26 " GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.",14 This patient was seen in clinic for a school physical.,29 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,33 " Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. ",15 " Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. ",38 Epigastric herniorrhaphy. Epigastric hernia.,38 Neurologic examination sample. ,5 Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,38 Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,38 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,28 Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,38 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.,5 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.,38 Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,35 Patient referred for narrow angles and possible associated glaucoma.,26 2-D Echocardiogram,3 " Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",15 " A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",16 A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,35 " Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.",10 The patient was referred due to concerns regarding behavioral acting out as well as encopresis.,32 Full mouth dental rehabilitation in the operating room under general anesthesia.,38 " Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",38 " The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. ",5 Emergency cesarean section.,24 " Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.",28 " Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.",38 Psychiatric consultation for management of pain medications.,32 Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. ,38 Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus.,38 " Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",5 " Microscopic hematuria with lateral lobe obstruction, mild.",38 Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.,33 Sample female exam and review of systems.,15 " 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.",3 Right ear examination under anesthesia. Right tympanic membrane perforation along with chronic otitis media.,38 Patient complains of constipation. Has not had BM for two days.,14 " 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.",38 CT brain (post craniectomy) - RMCA stroke and SBE.,22 Bilateral myringotomies with insertion of Santa Barbara T-tube.,38 Hand dermatitis.,8 Sepsis due to urinary tract infection.,15 " DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,",3 Chest CT - Thymoma and history of ocular myasthenia gravis.,33 " Left orchiectomy, scrotal exploration, right orchidopexy.",38 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. ,38 " Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.",14 Right lower pole renal stone and possibly infected stent. Cysto stent removal.,21 " Right shockwave lithotripsy, cystoscopy, and stent removal x2.",38 " A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.",14 A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,16 " Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",38 " A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.",29 Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 " Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",15 " 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. ",27 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,33 Patient with a past medical history of hypertension for 15 years.,5 Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,27 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.,33 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,38 Complaint of mood swings and tearfulness.,5 " Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.",38 Bilateral vasovasostomy surgery sample.,39 Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.,14 Dietary consultation for diabetes during pregnancy.,9 " New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.",5 " Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ",38 " Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. ",5 " Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.",14 Increasing oxygen requirement. Baby boy has significant pulmonary hypertension. ,3 " A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.",15 MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.,22 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.,27 A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,24 " C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",23 Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,38 The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.,38 " History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.",30 Repair of ruptured globe involving posterior sclera - Sample/Template. ,38 " The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.",26 " A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",5 Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,38 " 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.",24 Trauma/ATV accident resulting in left open humerus fracture.,10 Pain management sample progress note.,35 " Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.",27 The patient was referred due to concerns regarding behavioral acting out as well as encopresis.,5 " Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",12 " Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.",15 Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 CT chest with contrast.,3 Bilateral vasovasostomy surgery sample.,38 " Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants. Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.",24 Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.,3 Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,35 " C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",27 " Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.",24 " Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.",5 Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. ,36 " EGD with photos and biopsies. This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently. ",38 Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,26 " New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ",5 " Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",38 " Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.",27 " Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.",38 " Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 " Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.",38 Laparoscopic-assisted vaginal hysterectomy. Abnormal uterine bleeding. Uterine fibroids.,38 Common Excretory Urogram - IVP template,33 Unilateral transpedicular T11 vertebroplasty.,27 Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. ,38 Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,38 " Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 " Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.",28 Circumcision in an older person,39 A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,16 " Woman with adult hydrocephalus, routine evaluation. ",22 Marked right hydronephrosis without hydruria. ,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.",38 " Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 " Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.",35 Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,38 " Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. ",5 " The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",5 " Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",5 Discharge summary of a patient with depression and high risk behavior.,10 Patient with worsening shortness of breath and cough.,3 An example/template for a routine normal male ROS.,25 Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 " Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 " Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.",38 ,14 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.,38 " 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.",14 Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,3 Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.,27 " Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",22 Patient referred for narrow angles and possible associated glaucoma.,20 " Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",14 MRI Brain and Brainstem - Falling (Multiple System Atrophy),22 " Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.",38 Right nodular malignant mesothelioma.,38 Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,14 " Well-child check sports physical - Well child asthma with good control, allergic rhinitis.",29 " Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. ",27 " Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",27 Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. ,29 " A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ",33 " Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.",14 " 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.",3 The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,27 " Patient with several medical problems - numbness, tingling, and a pain in the toes.",5 Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,14 Lower Extremity Arterial Doppler,3 Arterial imaging of bilateral lower extremities. ,3 Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,38 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,38 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.,27 A female with unknown gestational age who presents to the ED after a suicide attempt.,12 " Anxiety, alcohol abuse, and chest pain. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. ",15 Consult for laparoscopic gastric bypass.,5 MRI report Cervical Spine (Chiropractic Specific),33 " This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. ",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.,23 " Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",23 Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,38 Psychiatric consultation for substance abuse.,32 Patient in ER complaining of shortness of breath (COPD),3 The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 Marked right hydronephrosis without hydruria. ,21 Left lower lobectomy.,3 " Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",31 An example/template for a routine normal female physical exam.,5 Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.,38 " 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.",15 " Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.",35 Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.,38 A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,3 " 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.",33 Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina.,3 " Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management",5 " Sample normal ear, nose, mouth, and throat exam.",11 Central line insertion. Empyema thoracis and need for intravenous antibiotics.,3 A 12-year-old young man with sinus congestion.,15 The patient has NG tube in place for decompression.,35 " Left heart catheterization, left ventriculography, selective coronary angiography.",38 CT scan of the abdomen and pelvis without and with intravenous contrast.,14 Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,26 Emergency cesarean section.,38 Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. ,38 Colonoscopy to evaluate prior history of neoplastic polyps.,38 Overactive bladder with microscopic hematuria.,35 Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,38 " Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.",38 " Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.",38 Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 Progressive loss of color vision OD.,22 CT REPORT - Soft Tissue Neck,27 A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,10 " Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 " This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. ",22 " Congestion, tactile temperature.",29 Primary low segment cesarean section.,24 " Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.",3 " Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.",38 " Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",22 " Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",16 An example/template for a routine normal female physical exam.,25 " Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",38 Endoscopic release of left transverse carpal ligament.,38 Vitrectomy under general anesthesia,38 " Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.",24 " Orthopedic progress note for follow up of osteoarthritis, knees.",27 " Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.",27 " Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.",3 " Right total knee arthroplasty - Osteoarthritis, right knee.",27 Endoscopic proximal shunt revision.,23 Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 " 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. ",5 " Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.",38 Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. ,10 Pediatric Gastroenterology - History of gagging.,29 " Chest pain, Chest wall tenderness occurred with exercise.",3 Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. ,3 Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection.,35 " Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.",27 " Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.",38 " Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.",38 " Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",21 " CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",22 Psychiatric History and Physical - Patient with schizoaffective disorder.,32 " Followup diabetes mellitus, type 1.",13 " Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.",38 " The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. ",5 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,27 Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. ,38 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.,27 Elevated PSA with nocturia and occasional daytime frequency.,35 " Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. ",38 " Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.",27 " Patient with a history of PTSD, depression, and substance abuse.",5 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.,33 " Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.",3 Patient with stable expressive aphasia and decreased vision.,22 " Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ",23 Patient with worsening shortness of breath and cough.,15 Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,15 " Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",15 " Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.",33 " Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. ",29 " Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",38 " Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.",26 " Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.",3 " Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.",3 Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,38 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,27 " Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.",38 Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.,12 Patient with right ankle pain.,27 " Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",31 " Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization.",38 Normal vasectomy,39 Closed reduction and pinning of the right ulna with placement of a long-arm cast.,27 Echocardiogram was performed including 2-D and M-mode imaging.,33 " Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant. Chronic pelvic pain, probably secondary to endometriosis.",24 " 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..",15 The patient is being discharged for continued hemodialysis and rehab.,21 A simple note on Acne Vulgaris.,8 " 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.",27 " Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.",38 " Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",38 " Left orchiopexy. Ectopic left testis. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.",39 " Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",35 " An 18-year-old white female who presents for complete physical, Pap, and breast exam.",24 " Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.",38 " Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.",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. ",38 Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain,25 Patient today with multiple issues. ,35 Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.,38 The patient admitted with palpitations and presyncope.,5 " Excision of lipoma, left knee. A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.",38 Foul-smelling urine and stomach pain after meals.,5 " 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.",27 Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 Right carpal tunnel syndrome. Right carpal tunnel release.,27 " 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. ",38 Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,3 Bilateral open carpal tunnel release.,27 Insertion of transvenous pacemaker for tachybrady syndrome,3 " Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",16 Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,25 " A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.",15 " 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.",38 Return to work & Fit for duty evaluation.,15 The patient needs refills on her Xanax,15 " Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.",5 " 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.",16 " Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",3 " Left inguinal herniorrhaphy, modified Bassini. Left inguinal hernia, direct.",38 " Re-excision of squamous cell carcinoma site, right hand.",16 " 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.",23 Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.,5 Evaluation for right L4 selective nerve root block.,27 " BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.",24 " Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.",31 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.,38 Noncontrast CT head due to seizure disorder.,33 Endoscopic carpal tunnel release. Left carpal tunnel syndrome.,27 An example/template for a routine normal female physical exam.,15 Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,27 " Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.",38 " Needle-localized excisional biopsy of the left breast. Left breast mass with abnormal mammogram. The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.",38 Left partial nephrectomy due to left renal mass.,38 MRI Brain & T-spine - Demyelinating disease.,22 A white female with a history of fevers.,10 " Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.",26 " Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",27 A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation.,14 " Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.",14 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,11 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,22 " Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.",33 1-year well child check.,29 " Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.",38 " Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",10 " Specimen labeled ""sesamoid bone left foot"".",19 " 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.",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.",15 " The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. ",39 The patient states that he feels sick and weak.,15 " Appendicitis, nonperforated. Appendectomy. A transverse right lower quadrant incision was made directly over the point of maximal tenderness. ",14 " Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",27 " Left thyroid mass. Left total thyroid lumpectomy. The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 Left lower extremity venous Doppler ultrasound,33 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,16 " Cystoscopy, cryosurgical ablation of the prostate.",38 A 37 year-old female with twin pregnancy with threatened premature labor.,24 " Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.",14 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.,22 " First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",15 " Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",10 Patient being referred for evaluation of glaucoma.,26 The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,3 An example/template for a routine normal male physical exam.,5 Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.,27 " MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.",22 Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. ,27 " Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week",5 Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. ,38 " Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.",38 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,5 The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,3 Patient today with ongoing issues with diabetic control.,35 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage. ,38 " Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. ",22 PICC line insertion,38 CT REPORT - Soft Tissue Neck,33 " Sterilization candidate. Cervical dilatation and laparoscopic bilateral partial salpingectomy. A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.",38 Pediatric Gastroenterology - Rectal Bleeding Consult.,5 Laparoscopic bilateral tubal ligation with Falope rings.,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.",5 Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 Patient with intermittent episodes of severe nausea and abdominal pain.,5 " The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.",38 " Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs",27 " Left orchiectomy, scrotal exploration, right orchidopexy.",39 Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.,38 " Circumcision. A dorsal slit was made, and the prepuce was dissected away from the glans penis.",38 Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,24 " Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",16 " Sample normal ear, nose, mouth, and throat exam.",15 " Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. ",15 Ultrasound BPP - Advanced maternal age and hypertension.,24 " Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.",38 " Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.",39 Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.,27 A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.,5 Routine colorectal cancer screening. He occasionally gets some loose stools. ,14 " 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. ",22 " Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes.",22 " Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",27 " Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid. Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.",24 Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,5 2-month-old female - increased work of breathing.,12 " 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.",15 " Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",27 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,38 " Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",38 Multiple stent placements with Impella circulatory assist device.,3 Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. ,15 Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally.,39 MRI for Arnold Chiari II with syrinx,22 Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. ,16 A 5-month-old boy brought by his parents because of 2 days of cough. ,29 This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 An example/template for a routine normal male physical exam.,15 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.,16 " 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.",23 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.,3 MRI cervical spine.,33 " Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. ",14 Concomitant chemoradiotherapy for curative intent patients.,33 " 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.",3 " 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.",3 Occupational medicine consult with questions-answers and records review.,5 " The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.",32 " Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.",27 Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,29 Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.,38 The patient seeks evaluation for a second opinion concerning cataract extraction. ,26 Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,22 Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.,38 Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,38 Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,23 Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,5 Bladder instillation for chronic interstitial cystitis.,39 Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,5 " Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.",3 Repeat cesarean section and bilateral tubal ligation.,24 " Sample normal ear, nose, mouth, and throat exam.",15 Adenoidectomy procedure,11 Common CT C-Spine template,27 MRI L-Spine - Bilateral lower extremity numbness,27 She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.,38 " A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",35 Common CT Neck template.,11 " Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.",38 " Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.",27 " Right hand laceration x3, repaired.",25 " Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. ",14 " A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 " 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).",38 Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.,38 " Congestion, tactile temperature.",5 A 21-channel digital electroencephalogram was performed on a patient in the awake state.,22 " A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.",15 " Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.",33 An example/template for a routine normal female physical exam.,15 Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.,27 Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization. Intrauterine pregnancy at 35-1/7. Rh isoimmunization. Suspected fetal anemia. Desires permanent sterilization.,24 Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.,3 Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,27 " Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.",38 A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,3 " Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",11 Closed reduction and pinning of the right ulna with placement of a long-arm cast.,38 Cystoscopy and removal of foreign objects from the urethra.,39 Psychiatric consultation for substance abuse.,5 Common description of colonoscopy,14 Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,38 " Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",35 Sample progress note - Gen Med.,35 MRI Cervical Spine without contrast.,27 MRI Head W&WO Contrast.,33 The patient is status post C3-C4 anterior cervical discectomy and fusion.,33 " The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ",32 Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%,3 " Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.",38 " Austin bunionectomy with internal screw fixation, first metatarsal, left foot.",27 " Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",38 Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.,3 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.,22 " Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",35 CT scan of the abdomen and pelvis without and with intravenous contrast.,21 The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,5 " MRI of the Cervical, Thoracic, and Lumbar Spine",27 Total colonoscopy with biopsy and snare polypectomy.,38 Phacoemulsification with posterior chamber intraocular lens - Sample/Template.,38 " GI Consultation due to rectal bleeding, positive celiac sprue panel",14 " Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.",38 Mother states he has been wheezing and coughing.,29 " Intractable epilepsy, here for video EEG.",5 " Right inguinal hernia. Right inguinal hernia repair. The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",38 One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 " Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.",38 " Phacoemulsification of cataract, extraocular lens implant in left eye.",26 Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.,28 Urgent cardiac catheterization with coronary angiogram.,3 Normal child physical exam template.,5 " Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.",15 " Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.",14 Holter monitor report. Predominant rhythm is sinus. Triplet maximum rate of 178 beats per minute noted.,3 HCT: Subdural hemorrhage.,22 A 9-month well-child check.,29 " Closure of rectovaginal fistula, transperineal approach",38 The patient with continued problems with her headaches. ,25 Consultation for evaluation of thrombocytopenia.,16 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.,22 Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,38 Right middle ear exploration with a Goldenberg TORP reconstruction.,38 " 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. ",39 " Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.",3 Evaluation for right L4 selective nerve root block.,28 Upper endoscopy with removal of food impaction.,14 Blepharoplasty procedure,6 " Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. ",5 " Total Abdominal Hysterectomy (TAH). An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. ",24 This is a middle-aged female with two month history of low back pain and leg pain.,33 Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,38 " Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 " The patient comes for three-week postpartum checkup, complaining of allergies.",24 " Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",22 " Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. ",38 Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery.,22 " The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ",14 Diagnostic fiberoptic bronchoscopy.,38 The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. ,32 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.,3 Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed,39 " Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. ",14 " The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. ",3 " Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue",15 A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. ,5 Debridement left ischial ulcer.,14 Total colonoscopy and polypectomy,14 Aftercare of multiple trauma from an motor vehicle accident.,10 Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. ,31 Chiropractic IME with answers to questions from Insurance Company.,18 " Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",16 Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,35 Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. ,14 " Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.",15 " 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.",15 Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,5 Thoracentesis. Left pleural effusion. Left hemothorax.,3 Consultation for left foot pain.,4 " Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",35 Right upper lung lobectomy. Mediastinal lymph node dissection,38 Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning.,39 An example/template for meatoplasty.,38 CT Brain: Subarachnoid hemorrhage.,22 " Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.",5 Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,38 A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.,35 Reflex sympathetic dystrophy of both lower extremities.,22 " 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. ",22 " Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 Dietary consultation for carbohydrate counting for type I diabetes.,35 " Aortic stenosis. Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.",38 Mother states he has been wheezing and coughing.,0 Axial images through the cervical spine with coronal and sagittal reconstructions.,33 Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.,33 Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. ,38 " Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. ",30 " Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",25 Bilateral sacroiliac joint injections,28 " Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.",38 Cadaveric renal transplant to right pelvis - endstage renal disease.,21 MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),33 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.,3 " Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.",3 Open reduction and internal fixation of left distal radius.,38 Patient in with mom for possible ear infection.,5 Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,10 Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis,14 " Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.",3 Laparoscopic appendectomy. Acute appendicitis.,14 Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,10 Discharge summary of a patient with depression and high risk behavior.,32 " A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.",5 Underwent tonsillectomy and adenoidectomy two weeks ago. ,25 Headache and diplopia.,22 " Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.",12 " A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 " 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.",3 " The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved.",10 Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,38 Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe.,3 " Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. ",5 Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 " Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",5 Bilateral endoscopic proximal shunt revision and a distal shunt revision.,38 " A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. ",5 Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. ,3 Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at term with previous cesarean section. Desires permanent sterilization. Macrosomia.,24 " Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",5 " Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",35 Acute appendicitis with perforation. Laparoscopic appendectomy. A CT scan of abdomen showed evidence of appendicitis with perforation. ,38 " Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",27 " Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ",38 " Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication. ",3 Patient complains of constipation. Has not had BM for two days.,25 " Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",23 " CT abdomen and pelvis without contrast, stone protocol, reconstruction.",14 " Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.",14 The patient has NG tube in place for decompression.,15 A female for a complete physical and follow up on asthma with allergic rhinitis.,0 " Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",11 Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.,24 Sleep study - patient with symptoms of obstructive sleep apnea with snoring.,36 Left third digit numbness and wrist pain.,22 " Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.",39 " Toenails are discolored, thickened, and painful - Onychomycosis",31 A 37 year-old female with twin pregnancy with threatened premature labor.,33 Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. ,26 " Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.",38 Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,23 Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,12 Questionable need for antibiotic therapy for possible lower extremity cellulitis.,5 " Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.",38 Plastic piece foreign body in the right main stem bronchus. Rigid bronchoscopy with foreign body removal.,3 Open radical retropubic prostatectomy with bilateral lymph node dissection.,39 " Toenails are discolored, thickened, and painful - Onychomycosis",5 " Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. ",5 Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,3 Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,33 Revision right total knee arthroplasty. Right failed total knee arthroplasty.,27 " Severe tonsillitis, palatal cellulitis, and inability to swallow.",11 Template for History and Physical for a newborn.,25 " 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.",24 A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy. ,16 " Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.",3 Colonoscopy. Change in bowel habits and rectal prolapse. Normal colonic mucosa to the cecum. ,14 " Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast.",38 " The patient with gradual onset of a headache problem, located behind both eyes.",5 Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.,38 Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.,14 " General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, ",35 Left heart cardiac catheterization.,3 Right undescended testicle. Orchiopexy & Herniorrhaphy.,39 " A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",29 Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,16 " Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.",33 " 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.",38 Dysarthria. Probable brainstem glioma.,22 " Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years. ",38 Bilateral temporal artery biopsy. Rule out temporal arteritis.,23 Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,38 Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,24 Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,38 " C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.",38 " 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.",22 " 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",5 " The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",15 " Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps.",38 Sample female physical exam,15 " Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",23 A 53-year-old female with left knee pain being evaluated for ACL tear.,33 A female for a complete physical and follow up on asthma with allergic rhinitis.,3 Pain and swelling in the right foot.,31 " Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",15 Autopsy - Homicide - Blunt force cranial trauma,1 Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,14 " Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.",38 Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.,3 " Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.",38 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.,8 " The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.",10 " Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants. Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.",38 " Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",33 " Acute gastroenteritis, resolved. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.",14 Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,3 " 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.",16 " Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.",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. ",38 " Left below-the-knee amputation. Dressing change, right foot.",38 " Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.",38 Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.,38 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.,33 " Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.",10 Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.,3 " Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",21 The patient underwent an overnight polysomnogram.,36 " Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.",10 Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones.,14 Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva.,24 Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 " A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.",39 " Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. ",5 " Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",15 Intermittent rectal bleeding with abdominal pain.,38 Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.,38 " 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. ",38 Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,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.,24 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,3 Diagnostic Mammogram and ultrasound of the breast.,33 " Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm",33 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,26 " Exploratory laparotomy, lysis of adhesions, and right hemicolectomy. Right colon cancer, ascites, and adhesions.",14 An example of a physical exam,5 Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.,3 " Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",15 " Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.",5 Patient presents with complaint of lump in the upper outer quadrant of the right breast,5 Left lower extremity venous Doppler ultrasound,3 " Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. ",5 " Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",24 A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.,35 " 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.",12 Preop evaluation regarding gastric bypass surgery.,35 " 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. ",38 " Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",35 Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. ,12 Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved. ,32 A sample note on Rheumatoid Arthritis,34 " History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy.",14 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. ,39 Flexible sigmoidoscopy due to rectal bleeding.,14 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).,27 Patient presents with complaint of lump in the upper outer quadrant of the right breast,16 History and Physical for right ankle sprain,27 Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,27 Post-surgical medical management; right total knee replacement.,5 Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. ,37 Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.,38 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.,27 " Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 Coil embolization of patent ductus arteriosus.,3 A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,16 Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,33 Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 The patient seeks evaluation for a second opinion concerning cataract extraction. ,35 Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.,14 CT of the facial bones without contrast due to hit in nose.,33 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,22 Bilateral Myringotomy with placement of PE tubes,38 Neurologic examination sample. ,22 Common CT Chest template,33 " Acute foot or ankle sprain, possible small fracture.",12 Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.,38 CT of the abdomen and pelvis without contrast.,14 " 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.",29 " A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle.",35 " A 49-year-old female with ankle pain times one month, without a specific injury. ",31 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,38 " Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. ",38 " Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",39 " Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.",38 " Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy",38 Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.,39 " Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.",38 Patient comes for discussion of a screening colonoscopy. ,5 Right pontine pyramidal tract infarct.,22 Lower lid blepharoplasty.,26 " 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.",3 " Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",5 A 5-month-old boy brought by his parents because of 2 days of cough. ,5 Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,21 Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration.,24 Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.,38 Patient presents complaining of abdominal pain and discomfort for 3 weeks.,15 Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. ,38 Laparoscopic right partial nephrectomy due to right renal mass.,21 " Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.",38 Ophthalmology followup visit note.,26 Invasive carcinoma of left breast. Left modified radical mastectomy.,24 Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 " Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",26 " Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",10 Left testicular swelling for one day. Testicular Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles.,39 MRI cervical spine.,22 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.,12 Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,38 " 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.",5 " Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",11 " Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.",38 3-1/2-year-old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias.,38 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,23 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.,28 " Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.",24 A 21-channel digital electroencephalogram was performed on a patient in the awake state.,36 " Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.",14 Appendicitis. Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants.,14 " MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.",27 Newborn circumcision. The penile foreskin was removed using Gomco. ,38 " Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",38 The patient is status post C3-C4 anterior cervical discectomy and fusion.,22 Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,16 Injection of bilateral carpal tunnels,28 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,27 " Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, ",15 " C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.",27 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,12 " Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",38 " He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.",35 Ultrasound of pelvis - menorrhagia.,33 " Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",24 " This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.",22 " 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.",38 A white female presents for exam and Pap.,5 Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 Sleep study - patient with symptoms of obstructive sleep apnea with snoring.,22 Sellar HCT - Pituitary mass,33 " Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",12 " Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. ",38 Patient today with multiple issues. ,15 Neurologic examination sample. ,35 Right upper lung lobectomy. Mediastinal lymph node dissection,3 " A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",38 Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.,38 Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,5 Fertile male with completed family. Elective male sterilization via bilateral vasectomy.,39 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.,33 Noncontrast CT abdomen and pelvis per renal stone protocol.,33 " Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.",38 A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.,35 " Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.",3 MRI report Cervical Spine (Chiropractic Specific),4 Patient comes for discussion of a screening colonoscopy. ,14 Ultrasound-Guided Paracentesis for Ascites,14 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 " Fever, otitis media, and possible sepsis.",11 MRI right ankle.,33 Right and Left carotid ultrasound ,3 Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,15 Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.,38 Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. ,26 Left heart cardiac catheterization.,38 Patient developed iron deficiency anemia and had blood in his stool. ,35 Common CT Neck template.,33 Costochondral Cartilage Injection,28 Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. ,35 An example/template for a routine normal male physical exam.,15 " Intercostal block, left. Severe post thoracotomy pain.",28 Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.,5 Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,38 Fall/loss of consciousness.,5 Common description of colonoscopy,38 " Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",12 Urgent cardiac catheterization with coronary angiogram.,12 " Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",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.",9 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 Generalized abdominal pain with swelling at the site of the ileostomy. 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 " Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.",38 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.,27 " Austin bunionectomy with internal screw fixation, first metatarsal, left foot.",38 " Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week",39 Pain. Three views of the right ankle. Three views of the right ankle are obtained.,33 Laparoscopic right partial nephrectomy due to right renal mass.,38 " Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.",35 " Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",23 Letter to the patient to let him know about his abnormal cholesterol test results.,20 " Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.",38 Left flank pain and unable to urinate.,39 " Patient with hypertension, syncope, and spinal stenosis - for recheck.",35 Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 " Irritable baby, 6-week-old, with fever for approximately 24 hours.",5 Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.,38 Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,22 Occupational medicine consult with questions-answers.,5 Patient status post lap band placement.,35 " Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.",38 " CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.",33 " Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",26 A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,10 Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.,35 " The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",5 Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,25 " Sterilization candidate. Cervical dilatation and laparoscopic bilateral partial salpingectomy. A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.",24 " Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.",38 " Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.",38 Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. ,38 " Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",5 " Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,38 " Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth 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. ",27 " C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",23 " Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.",38 Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.,38 Normal Circumcision,38 Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,38 " 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.",5 Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. ,38 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.,7 " Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.",14 Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,10 " Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.",24 Psychiatric Consultation of patient with major depression disorder.,5 Right subclavian triple lumen central line placement,38 " Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.",27 " Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.",3 " Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.",38 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.,11 " A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",35 " Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 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. ,38 Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,10 " Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",10 Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. ,16 Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.,14 " 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.",38 " Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",15 " BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.",33 " Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.",35 Bilateral carotid ultrasound to evaluate pain.,3 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,31 MRI left knee without contrast.,33 Echocardiogram with color flow and conventional Doppler interrogation.,33 " Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.",27 " Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.",27 " Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. ",27 A sample note on Angina.,3 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.,28 MRI demonstrated right contrast-enhancing temporal mass.,35 Standard celiac plexus block procedure note.,28 Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,5 " 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.",38 " Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.",5 " Medical management, status post left total knee arthroplasty.",5 " Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.",5 " Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.",33 Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,5 " Ultrasound abdomen, complete",14 Speech therapy discharge summary. The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. ,37 Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.,38 " A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. ",5 " This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ",32 Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings),33 " 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.",28 A female with unknown gestational age who presents to the ED after a suicide attempt.,24 " Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum",38 " Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty. Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.",38 " Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.,27 Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,22 " Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy. ",38 Parotidectomy procedure,38 " School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",35 Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.,27 " Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.",5 Right ear pain with drainage - otitis media and otorrhea.,11 " 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.",27 " Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.",39 A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,12 " Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.",5 Esophagogastroduodenoscopy with biopsy.,38 She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,12 Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,27 " To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.",3 " Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.",38 A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.,3 " Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.",5 Cadaveric renal transplant to right pelvis - endstage renal disease.,38 " Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",31 Dobutrex stress test for abnormal EKG,33 Right Achilles tendon rupture.,27 " Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.",15 " Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.",21 Patient returns for his first followup after shunt surgery.,22 " Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",27 Ruptured globe with full-thickness corneal laceration repair - Sample/Template.,38 Normal child physical exam template.,15 Trabeculectomy with mitomycin C - Sample/Template.,26 A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.,5 " Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",38 A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,12 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. ,5 " The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ",22 MRI Elbow - A middle-aged female complaining of elbow pain.,27 Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,5 Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,5 A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,5 " Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",27 " Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.",38 Parotidectomy procedure,11 Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,38 " Grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary - Omentectomy, pelvic lymph node dissection, and laparoscopy.",38 Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,38 A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,12 Pulmonary Function Test in a patient with smoking history.,3 " Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",15 " 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.",32 " Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",21 Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.,35 " Followup diabetes mellitus, type 1.",15 Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.,3 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,33 " Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",15 Bilateral open Achilles lengthening with placement of short leg walking cast.,38 " Normal physical exam template. Normocephalic. Negative lesions, negative masses.",25 The patient needing to be reintubated due to a leaking ET tube. The patient is recently postoperative. ,38 Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 " Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.",33 " Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.",27 " Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",38 " Primary cesarean section by low-transverse incision. Term pregnancy, nonreassuring fetal heart tracing.",24 " The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ",10 Patient returns for his first followup after shunt surgery.,5 Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,3 Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.,14 " Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.",38 " Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",27 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.,3 Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis.,28 Circumcision and release of ventral chordee.,39 CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.,33 " CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.",22 " Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs",5 An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,38 " Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.",38 Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.,38 " 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. ",3 A 53-year-old female with left knee pain being evaluated for ACL tear.,27 Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. ,38 Bronchoscopy. Atelectasis and mucous plugging.,3 " Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.",38 Carotid Ultrasonic & Color Flow Imaging,33 Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,22 Preop evaluation regarding gastric bypass surgery.,2 " The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving.",22 " 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.",38 Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,38 Significant pain in left lower jaw.,7 Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.,3 Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated. ,28 " Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.",38 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage. ,27 Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally.,38 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,27 Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,29 " 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. ",38 " Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.",38 Carotid Ultrasonic & Color Flow Imaging,3 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,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.",6 GI Consultation for Chrohn's disease.,14 " Questionable foreign body, right nose. Belly and back pain. Mild constipation.",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.",10 " Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 " Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",21 " Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.",38 Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. ,2 Common description of EGD.,38 Left supraorbital deep complex facial laceration measuring 6x2 cm. Plastic closure of deep complex facial laceration measuring 6x2 cm. The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.,38 " Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",16 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,38 Patient presents for a colostomy reversal as well as repair of an incisional hernia. ,5 Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,38 A white female with a history of fevers.,15 " Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.",3 " Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.",38 Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,11 Excision of penile skin bridges about 2 cm in size.,38 " Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.",14 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,26 Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.,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. ",39 " Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.",11 " Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 A well-child check with concern of some spitting up quite a bit.,29 " CT abdomen and pelvis without contrast, stone protocol, reconstruction.",33 Full mouth dental rehabilitation in the operating room under general anesthesia.,7 " Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",15 Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.,38 Problem of essential hypertension. Symptoms that suggested intracranial pathology.,35 Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.,27 Right pleural effusion and suspected malignant mesothelioma.,16 MRI Head W&WO Contrast.,22 " 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.",3 4-day-old with hyperbilirubinemia and heart murmur.,29 " Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. ",38 " Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability.",3 Superior labrum anterior and posterior lesion repair.,38 " Negative for any nausea, vomiting, fevers, chills, or weight loss.",5 " 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.",3 Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,35 Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,38 Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis.,15 Left direct and indirect inguinal hernia. Repair of left inguinal hernia with Prolene mesh. The patient was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,39 CT Abdomen & Pelvis W&WO Contrast,21 " Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",39 " New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.",27 " Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.",5 An example/template for meatoplasty.,39 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,22 " Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",15 " Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",27 " The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",16 " Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.",15 Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.,27 " Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.",24 Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. ,28 Admission Psychiatric Evaluation,32 " Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.",15 " Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.",27 Consult for laparoscopic gastric bypass.,2 An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,5 A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,3 " Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.",28 Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.,5 " Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.",5 " Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",23 Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. ,14 " Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.",38 The patient has a possibly torsion detorsion versus other acute testicular problem. ,12 " Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.",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. ,33 " 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.",3 " Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",22 Occupational medicine consult with questions-answers and records review.,5 " The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.",15 " A 49-year-old female with ankle pain times one month, without a specific injury. ",33 " A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. ",10 A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,38 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. ,38 Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,35 " Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",11 " Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.",27 MRI Brain - Olfactory groove meningioma.,22 " To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.",5 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.,14 " The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 MRI Orbit/Face/Neck with MR Angiography of the Head - An infant with facial mass,33 " Brachytherapy, iodine-125 seed implantation, and cystoscopy.",39 Nuclear cardiac stress report. Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,3 " Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, ",5 " White male with onset of chest pain, with history of on and off chest discomfort over the past several days.",3 " Orthopedic progress note for follow up of osteoarthritis, knees.",35 " 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.",27 Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy. ,38 Prostate adenocarcinoma and erectile dysfunction - Pathology report.,39 Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.,38 Invasive carcinoma of left breast. Left modified radical mastectomy.,38 " Repeat low-transverse cesarean section via Pfannenstiel incision. Intrauterine pregnancy at 39 and 1/7th weeks. Previous cesarean section, refuses trial of labor. Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.",38 " One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well.",35 Autopsy of a white female who died of acute combined drug intoxication.,1 A 3-month well-child check. ,5 " 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.",24 " Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.",38 " Patient with chest pains, CAD, and cardiomyopathy.",3 Status post cadaveric kidney transplant with stable function.,21 Right heart catheterization. Refractory CHF to maximum medical therapy.,3 Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 GI bleed. Upper gastrointestinal bleed. CBC revealed microcytic anemia.,14 Psychosocial evaluation of kidney donor. Questions - Answers,32 The patient is status post C3-C4 anterior cervical discectomy and fusion.,30 " C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",38 " Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",5 CT REPORT - Soft Tissue Neck,27 Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. ,22 Common description of EGD.,14 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,38 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. ,5 " The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.",22 " Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",38 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,33 Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.,12 Pain management sample progress note.,28 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.,3 " Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.",38 She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,26 " Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.",27 Psychiatric Consultation of patient with recurring depression.,5 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.,33 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,38 " VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.",38 " Needle-localized excisional biopsy, left breast. The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast. She had no palpable mass on physical exam. She does have significant family history with two daughters having breast cancer.",38 Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,5 " Status post brain tumor with removal. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. ",5 An example/template for a routine normal male physical exam.,25 " Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.",38 " Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes.",5 " Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.",3 " The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",5 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. ,35 " Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",31 Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.,38 Flexible bronchoscopy to evaluate the airway (chronic wheezing).,38 Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. ,5 " Acute foot or ankle sprain, possible small fracture.",31 " Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",3 " She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee.",28 A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,15 " Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",10 " Consult for hypertension and a med check. History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.",15 " An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis.",15 " Chest, Single view post OP for ASD (Atrial Septal Defect).",33 Dietary consultation for gestational diabetes.,35 " 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.",5 Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.,3 Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap. Adenocarcinoma of the prostate.,39 " Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.",38 " C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",27 Whole body radionuclide bone scan due to prostate cancer.,39 Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,10 Sample for Neuropsychological Evaluation,22 Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.,5 A 32-year-old male with shoulder pain.,33 Occupational medicine consult with questions-answers and records review.,18 Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,16 Colonoscopy with random biopsies and culture.,38 CT brain (post craniectomy) - RMCA stroke and SBE.,33 Sore throat - Upper respiratory infection.,15 Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,10 Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction.,3 " White male with onset of chest pain, with history of on and off chest discomfort over the past several days.",38 " A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.",5 A middle-aged female with memory loss.,22 " 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.",38 " Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.",3 Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.,14 History and Physical for right ankle sprain,5 " Adenotonsillectomy, primary, patient under age 12.",11 Patient presents complaining of abdominal pain and discomfort for 3 weeks.,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.",38 " Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.",3 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,38 Acne with folliculitis.,35 Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. ,10 " Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",3 " The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ",24 Nephrology office visit for followup of CKD.,21 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,27 Axial images through the cervical spine with coronal and sagittal reconstructions.,22 CCTA with cardiac function and calcium scoring.,3 Dental prophylaxis under general anesthesia.,38 " This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",5 Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,38 A 27-year-old female with a size and date discrepancy.,24 Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,26 Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.,38 " Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 " Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 " Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",38 " Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 " Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",38 " Incision and drainage (I&D) with primary wound closure of scalp lacerations. The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.",38 " Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.",15 " 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.",27 This is a middle-aged female with two month history of low back pain and leg pain.,27 " Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",12 Insertion of transvenous pacemaker for tachybrady syndrome,38 Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 " Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",38 Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,26 " Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.",38 Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,5 " Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.",27 Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,12 Aftercare of multiple trauma from an motor vehicle accident.,15 The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. ,38 " Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.",38 " Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.",5 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,22 " Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.",38 " Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.",38 " Colonoscopy, conscious sedation, and snare polypectomy.",38 " Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. ",27 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,38 Scleral Buckle opening under general anesthesia.,26 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,38 " Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",35 Total colonoscopy and polypectomy,38 " Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",5 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.,15 " Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",38 Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. ,14 Ultrasound - a 22-year-old pregnant female.,24 " Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)",35 " Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. ",38 Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.,38 " Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.",26 This is a 95.5-hour continuous video EEG monitoring study.,22 " Visually significant nuclear sclerotic cataract, right eye. Phacoemulsification with posterior chamber intraocular lens implantation, right eye.",38 Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. ,14 " Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",11 Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. ,11 " Removal of infected sebaceous cyst, right neck.",38 A sample note on RICE Therapy,27 Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis,5 Completion thyroidectomy with limited right paratracheal node dissection.,13 " CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.",33 Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.,5 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,33 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).,38 Standard hypogastric plexus block procedure note.,28 Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.,38 Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar,33 Consultation for wrist pain.,27 " A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.",38 " History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).",15 " Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.",26 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,27 " Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency",5 " Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",26 " Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 " A 44-year-old, 250-pound male presents with extreme pain in his left heel.",38 Exploratory laparotomy and right salpingectomy.,24 " Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.",38 " Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.",10 Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. ,5 " 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.",38 " Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.",5 The patient was admitted after undergoing a drawn out process with a small bowel obstruction.,10 " Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. ",3 " Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",25 Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,3 " Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.",38 " Creation of AV fistula, left wrist in the anatomic snuffbox.",38 CT of the abdomen and pelvis without contrast.,33 " Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.",15 The patient underwent a total vaginal hysterectomy.,24 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.,5 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,22 " Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",33 " Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.",22 She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.,24 " Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",26 MRI left knee without contrast.,27 " Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",15 Repair of ruptured globe involving posterior sclera - Sample/Template. ,26 " Request for consultation to evaluate stomatitis, possibly methotrexate related.",15 Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,11 " Status post brain tumor with removal. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. ",37 " Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.",3 Migraine headache - The patient was seen in the urgent care.,12 A 10 years of age carries a diagnosis of cystic fibrosis,5 " Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.",27 Well child - Left lacrimal duct stenosis,29 " Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.",3 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,33 " Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.",35 " This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. ",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.",27 Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,26 Colonoscopy to evaluate prior history of neoplastic polyps.,14 " Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.",27 " A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.",5 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.,17 Bronchoscopy for hypoxia and increasing pulmonary secretions,38 " Aortoiliac occlusive disease. Aortobifemoral bypass. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.",3 " Cervical cone biopsy, dilatation & curettage",38 Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,38 " Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",21 Generalized abdominal pain with swelling at the site of the ileostomy. 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.,33 " A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.",15 " Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.",39 Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.,38 " The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",38 " Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",6 " The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. ",38 Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,38 " Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",26 Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia.,39 Colpocleisis and rectocele repair.,38 " Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",16 Common description of colonoscopy,38 Symptomatic thyroid goiter. Total thyroidectomy.,10 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 Hand dermatitis.,35 " Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.",15 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,33 The patient has a possibly torsion detorsion versus other acute testicular problem. ,39 X-RAY of the soft tissues of the neck.,33 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.,12 " Closure of bladder laceration, during cesarean section.",39 Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax.,35 MRI L-Spine - Bilateral lower extremity numbness,22 " Colonoscopy, conscious sedation, and snare polypectomy.",14 " VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.",3 Punch biopsy of right upper chest skin lesion.,8 " Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ",23 Chest tube talc pleurodesis of the right chest.,3 " First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 " 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. ",33 Followup on weight loss on phentermine.,35 General Medicine SOAP note.,35 13 years old complaining about severe ear pain - Chronic otitis media.,29 Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization. Intrauterine pregnancy at 35-1/7. Rh isoimmunization. Suspected fetal anemia. Desires permanent sterilization.,38 " There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. ",5 Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. ,16 " 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.",27 " Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port.",38 Patient with complaint of symptomatic cholelithiasis.,10 " 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.",38 Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.,39 Consult for laparoscopic gastric bypass.,2 The patient has been suffering from intractable back and leg pain.,27 Consultation for evaluation of thrombocytopenia.,15 " Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.",27 Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,38 " Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",23 An example normal physical exam,25 Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.,14 " MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.",33 " Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.",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.",29 Open cholecystectomy (attempted laparoscopic cholecystectomy).,38 " Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. Right ventricular pacemaker lead placement and lead revision.",3 Whole body PET scanning.,33 " 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.",23 Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy. ,11 The patient was exercised according to standard Bruce protocol for 9 minutes.,3 " Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical",39 " 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.",32 Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,29 Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.,27 " Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",24 Neurologic consultation was requested to evaluate her seizure medication and lethargy.,22 A well-child check with concern of some spitting up quite a bit.,5 Well-child check and school physical.,5 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.,38 " Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.",3 Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. ,16 Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.,15 Sample progress note - Gen Med.,35 Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.,14 " Patient with atrial fibrillation with slow ventricular response, partially due to medications.",3 " Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography.",38 Patient today with ongoing issues with diabetic control.,13 MRI Brain - Olfactory groove meningioma.,33 MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,33 Full mouth dental rehabilitation in the operative room under general anesthesia.,38 " Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ",24 Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.,12 Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,27 Encephalopathy related to normal-pressure hydrocephalus.,30 " Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth 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 " Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 Patient presents for a colostomy reversal as well as repair of an incisional hernia. ,14 Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,35 " A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.",15 Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,38 Consultation for wrist pain.,4 Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,10 " A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. ",5 " Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.",27 An example/template for a routine normal male physical exam.,5 " The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. ",3 Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.,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. ,15 Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,38 Patient today with ongoing issues with diabetic control.,15 Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.,3 " Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy",38 " Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.",24 Common CT Chest template,3 Nephrology Consultation - Patient with renal failure.,21 " Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.",38 " Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",38 " Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",38 " Left pleural effusion, parapneumonic, loculated. Left chest tube placement.",3 " Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",39 Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,5 " Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.",27 " Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. ",5 " Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.",38 " Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ",14 " Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.",27 Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.,24 " Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue",5 " 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.",38 " The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.",10 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. ,14 CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.,22 Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. ,38 " 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. ",26 " Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.",38 " Psychiatric evaluation for ADHD, combined type.",32 Chronic cholecystitis without cholelithiasis.,14 Tonsillectomy. Tonsillitis. McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. ,38 This patient has reoccurring ingrown infected toenails.,38 " Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.",38 Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema.,38 " Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.",38 Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.,38 NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.,27 " Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",38 " Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 " Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.",38 Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,3 Normal child physical exam template.,29 Evaluation for chronic pain program,4 " Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.",14 " The patient comes for three-week postpartum checkup, complaining of allergies.",35 Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.,32 Left distal medial hamstring release.,38 Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. ,38 The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,25 Rhabdomyosarcoma of the left orbit. Left subclavian vein MediPort placement. Needs chemotherapy.,38 " Normal physical exam template. Well developed, well nourished, in no acute distress.",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.",38 " Missed abortion. Suction, dilation, and curettage.",38 " Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 " Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",22 Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe.,38 A 75-year-old female comes in with concerns of having a stroke.,35 " Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.",3 Preoperative visit for weight management with laparoscopic gastric banding,2 " This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",15 " 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.",22 " Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.",14 Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,38 " CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",21 The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.,35 " Upper endoscopy, patient with dysphagia.",14 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. ,24 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,14 " Transurethral resection of the bladder tumor (TURBT), large.",39 Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.,38 Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. ,5 " Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.",38 " CT abdomen and pelvis without contrast, stone protocol, reconstruction.",21 " Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",21 Creation of right brachiocephalic arteriovenous fistula.,38 " A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" ",22 " Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",11 " Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",38 Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,27 " 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. ",23 Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.,10 Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. ,15 Belly button piercing for insertion of belly button ring.,38 " Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. ",5 Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.,5 Exploratory laparotomy and right salpingectomy.,38 " Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.",3 " Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 Punch biopsy of right upper chest skin lesion.,38 " Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.",21 " Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.",38 Complete eye examination - Normal eye and vision exam.,26 " Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,5 " Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.",24 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.,8 Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,38 " Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location. ",38 " Chest pain, Chest wall tenderness occurred with exercise.",33 " Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",3 CT of Brain - Subacute SDH.,22 " Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.",39 " EGD and colonoscopy. Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.",14 " Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",38 Consult and Spinal fluid evaluation in a 15-day-old,38 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,38 Examination due to blood-borne pathogen exposure.,5 Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain,3 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.,12 Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,31 " Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",38 Incision and drainage of right buccal space abscess and teeth extraction.,38 Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.,38 Discharge summary of a patient with a BRCA-2 mutation.,10 The patient brought in by EMS with a complaint of a decreased level of consciousness.,15 " Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.",39 MRI left shoulder.,33 " Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.",3 " Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps.",14 " Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.",3 " 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.",38 Twin pregnancy with threatened preterm labor.,24 CT Abdomen & Pelvis W&WO Contrast,14 Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,38 " Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 " Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.",21 " Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye",26 Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,33 MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).,33 Direct laryngoscopy and bronchoscopy.,3 Well child - Left lacrimal duct stenosis,5 " Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",32 " The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. ",38 Upper endoscopy with foreign body removal (Penny in proximal esophagus).,38 Laparoscopic cholecystectomy with cholangiogram.,14 Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,35 " Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.",3 Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. ,33 Colonoscopy to screen for colon cancer,14 " The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations.",10 " Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.",11 Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,21 A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,22 " 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.",16 CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.,3 " Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.",27 " A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.",24 CT Scan of brain without contrast.,22 " A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.",39 " Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.",14 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.,36 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.,39 " Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. ",39 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,5 The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.,14 Cause of death - Anoxic Encephalopathy,1 " 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.",5 Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 Patient in ER complaining of shortness of breath (COPD),12 Consult and Spinal fluid evaluation in a 15-day-old,5 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 " Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.",39 " 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.",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.",3 Circumcision procedure (neotal),38 " Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. ",5 " Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",22 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,27 " Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.",33 Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.,14 Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,39 Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,27 OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.,38 " Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",5 " Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",5 Upper gastrointestinal endoscopy.,14 " Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",5 Esophagogastroduodenoscopy with biopsy.,14 Sample progress note - Gen Med.,15 Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.,32 Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.,14 " Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise.",3 " Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.",38 " Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.",14 Psychiatric consultation of patient with lethargy.,32 " Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",5 A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,15 Patient presents for treatment of suspected rheumatoid arthritis.,5 Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,38 " Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.",38 Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor. ,23 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,23 " Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.",10 Inguinal orchiopexy procedure.,39 " A 44-year-old, 250-pound male presents with extreme pain in his left heel.",35 " 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. ",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.",22 Patient with a 1-year history of progressive anterograde amnesia,22 Vitrectomy under local anesthesia.,38 " Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",8 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.,23 Common description of EGD.,14 Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.,27 " Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.",35 " Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.",39 " Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",39 " Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",5 Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 Initial clinic visit for foreign body in left eye.,15 " A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.",38 " Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.",22 " T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",11 The patient is in complaining of headaches and dizzy spells.,35 An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,31 " A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. ",3 Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection.,39 A middle-aged female with memory loss.,33 Common description of colonoscopy,14 " A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. ",5 " Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",38 Congestive heart failure (CHF) with left pleural effusion. Anemia of chronic disease.,10 Noncontrast CT abdomen and pelvis per renal stone protocol.,21 A 75-year-old female comes in with concerns of having a stroke.,22 " History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).",5 Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,33 Chest CT - Thymoma and history of ocular myasthenia gravis.,22 A 14-year-old young lady is in the renal failure and in need of dialysis.,38 The patient with continued problems with her headaches. ,22 " Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.",27 Discharge summary of a patient with mood swings and oppositional and defiant behavior.,32 " 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.",27 " Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",38 " Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.",39 " Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.",38 A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,5 " A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis",15 " Specimen labeled ""sesamoid bone left foot"".",27 " 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. ",7 Tonsillectomy. Chronic tonsillitis.,11 Nuclear Medicine Therapy Intraarterial Particulate Administration,33 " Primary cesarean section by low-transverse incision. Term pregnancy, nonreassuring fetal heart tracing.",38 Evaluation and recommendations regarding facial rhytids.,35 " Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",21 " Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.",15 HCT: Subdural hemorrhage.,33 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 " Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.",3 " Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",21 " Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.",39 Sample progress note - Gen Med.,35 Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. ,27 Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis. ,27 Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,15 Fall/loss of consciousness.,22 Reduction of paraphimosis.,39 " Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.",10 The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,10 Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 " T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",16 " 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.",27 " Phacoemulsification of cataract and posterior chamber lens implant, right eye.",38 Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 Frontal and lateral views of the hip and pelvis.,27 " Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).",24 Sample progress note - Gen Med.,15 " The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",35 " Patient with a history of PTSD, depression, and substance abuse.",32 Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,3 " A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. ",15 " She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.",35 " Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.",38 " Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.",24 Stage I and II neuromodulator.,38 " Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.",24 " Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.",15 Excisional biopsy of right cervical lymph node.,16 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,22 " Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.",38 " Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.",3 " Coronary artery bypass grafting (CABG) x4. Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.",3 " Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.",27 " Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 Patient in emergency room due to high potassium value.,15 " Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.",22 Primary low segment cesarean section.,38 " The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. ",35 Sepsis due to urinary tract infection.,35 Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.,3 " Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. ",5 " Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.",3 The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,29 " Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.",21 " Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.",3 " Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain",15 The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,38 Chiropractic Evaluation for neck and low back pain following a car accident.,4 " Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.",38 " Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.",38 " Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",3 " Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.",27 " The thoracic spine was examined in the AP, lateral and swimmer's projections.",33 " Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.",5 " Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 " Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.",5 Incision and drainage of left neck abscess.,38 Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,3 A 19-year-old right-handed male injured in a motor vehicle accident.,20 " Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.",38 Patient with complaint of symptomatic cholelithiasis.,14 Newborn circumcision. The penile foreskin was removed using Gomco. ,29 Initial clinic visit for foreign body in left eye.,5 Left Iliopsoas hematoma. Gait difficulty.,22 " Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",3 Transplant nephrectomy after rejection of renal transplant,38 " A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. ",39 Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,3 Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,35 " First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",5 Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. ,38 " Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.",15 " Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum",11 Chest pain. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.,3 " Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",16 A 66-year-old female with knee osteoarthrosis who failed conservative management.,27 An example/template for a routine normal male ROS.,5 " Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.",38 " Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.",38 Consultation for right shoulder pain.,27 Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.,28 " 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.",38 " Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.",38 A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath.,5 Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,38 Transvaginal ultrasound to evaluate pelvic pain.,24 " Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue, secondary closure of wound, and VAC insertion.",38 The patient had spraying of urine and ballooning of the foreskin with voiding.,39 Stress test with Bruce protocol due to chest pain.,33 " Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",38 " Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.",24 Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.,5 " Left heart catheterization, left ventriculography, selective coronary angiography.",3 " Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.",35 " Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",16 " Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.",38 " Left buttock abscess, status post incision and drainage. Recommended some local wound care",5 Belly button piercing for insertion of belly button ring.,6 " Diagnostic laparoscopy and laparoscopic appendectomy. Right lower quadrant abdominal pain, rule out acute appendicitis.",14 " The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ",35 The patient was referred due to a recent admission for pseudoseizures.,5 " 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.",3 Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. ,14 Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,5 " A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.",5 The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.,15 The patient is in complaining of headaches and dizzy spells.,15 The patient had undergone mitral valve repair about seven days ago. ,3 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.,16 " Stab wound, left posterolateral chest. Closure of stab wound.",38 Psychiatric consultation for alcohol withdrawal and dependance.,32 Sample/template for a normal female multisystem exam,25 Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 Acromioclavicular joint injection,28 " Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",31 " This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. ",3 Closure of gastrostomy placed due to feeding difficulties. ,38 Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.,38 Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 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. ,3 Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.,14 " Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.",38 A 12-year-old young man with sinus congestion.,5 " Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location. ",14 " Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 MRI left knee.,27 " Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",15 " Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",27 " A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. ",29 " Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 " Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.",38 Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,38 " Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",11 Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. ,10 Prostate Brachytherapy - Prostate I-125 Implantation,39 Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,22 Patient with swelling of lips and dysphagia and Arthritis.,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.",29 Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 " Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.",3 " Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.",38 " CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).",33 Migraine headache - The patient was seen in the urgent care.,15 " 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.",27 " Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left.",38 Common description of colonoscopy,38 " Missed abortion. Suction, dilation, and curettage.",24 " Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.",38 " He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ",20 An example of a physical exam,15 Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,35 " Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.",24 " Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.",38 Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery,3 Qualified medical evaluation report of a patient with back pain.,18 Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,14 " Right hand laceration x3, repaired.",15 " Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.",38 " Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left.",3 Revision and in situ pinning of the right hip.,38 Right ear pain with drainage - otitis media and otorrhea.,5 Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,27 Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,23 " Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.",27 " Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",15 Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,38 " Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",38 Patient with confusion and hallucinations.,5 " An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis.",5 " CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",27 Patient with history of adenomas and irregular bowel habits.,38 Chronic snoring in children,15 Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 The patient presents for a followup for history of erythema nodosum.,5 " Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",38 Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings),24 " A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.",35 CCTA with cardiac function and calcium scoring.,33 Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.,38 Postpartum tubal ligation and removal of upper abdominal skin wall mass.,24 Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning.,38 Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 " Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",39 Left direct and indirect inguinal hernia. Repair of left inguinal hernia with Prolene mesh. The patient was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,38 A 2-month-old female with 1-week history of congestion and fever x2 days.,15 Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization.,38 Epididymectomy,38 Anterior cranial vault reconstruction with fronto-orbital bar advancement.,38 Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar,3 Ultrasound - a 22-year-old pregnant female.,33 Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.,10 " A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",27 Left temporal craniotomy and removal of brain tumor.,23 Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.,38 Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,38 Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.,39 " Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.",38 Consultation for left foot pain.,27 " A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.",3 " 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.",30 " Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.",14 The patient admitted with palpitations and presyncope.,3 " Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.",38 L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,28 Blood in urine - Transitional cell cancer of the bladder.,39 A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.,3 The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness. ,5 Psychiatric consultation of patient with lethargy.,5 " Hardware removal, right ulnar",38 " EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.",38 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.,3 " Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.",38 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,23 Generalized abdominal pain with swelling at the site of the ileostomy. 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.,14 Phacoemulsification with posterior chamber intraocular lens insertion.,26 Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.,5 Patient scheduled for laparoscopic gastric bypass. ,2 The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time. ,5 " The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",5 " Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.",38 " The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions.",10 " Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.",5 " Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.",5 " Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.",38 " Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.",27 Stress test with Bruce protocol due to chest pain.,3 " A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the diagnosis of intracranial bleeding.",12 Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP).,38 Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 " Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.",3 " Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.",27 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.,14 Normal vasectomy,38 Patient with immune thrombocytopenia,15 " Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.",35 " Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",21 " Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.",14 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,23 Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,29 " Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.",38 The patient is being referred for evaluation of diabetic retinopathy.,26 Sentinel lymph node biopsy. Ultrasound-guided lumpectomy with intraoperative ultrasound.,38 " 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 " Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",31 A male referred to Wheelchair Clinic for evaluation for a new wheelchair. ,5 HCT for memory loss and for calcification of basal ganglia (globus pallidi).,22 " Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",21 " Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.",38 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.,33 " A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.",15 " Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.",14 Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.,22 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.,32 Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 Complaint of left otalgia (serous otitis) and headache. History of atopic dermatitis.,15 Short-term memory loss (probable situational) and anxiety stress issues.,15 Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,14 Questionable need for antibiotic therapy for possible lower extremity cellulitis.,15 Ligament reconstruction and tendon interposition arthroplasty of right wrist.,38 Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,21 " The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.",5 Epididymectomy,39 Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,12 " CT Brain: Suprasellar aneurysm, pre and post bleed.",22 " Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.",14 Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 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.,38 " The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. ",33 Common description of colonoscopy,38 Probable Coumadin hypersensitivity.,15 " Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.",3 Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.,27 Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias,3 Blepharoplasty with direct brow repair.,26 Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins.,38 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,27 " Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.",38 " Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.",38 History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.,15 Psychiatric consultation for management of pain medications.,5 Flexible bronchoscopy to evaluate the airway (chronic wheezing).,3 " The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders.",15 " Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.",5 " Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.",27 MRI right ankle.,31 Flexible sigmoidoscopy due to rectal bleeding.,38 " 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.",3 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. ,23 Cystopyelogram and laser vaporization of the prostate.,39 " Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",11 Electroencephalographic findings and interpretation,22 " Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.",26 " Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",5 Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,5 " Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",15 Lumbar puncture with moderate sedation.,22 " Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.",22 " Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. ",30 " Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",31 Colpocleisis and rectocele repair.,24 Trauma/ATV accident resulting in left open humerus fracture.,27 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,27 CT of abdomen with and without contrast. CT-guided needle placement biopsy.,38 " 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.",20 " 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.",38 " Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.",24 " Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast.",27 " Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",38 Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area. Pannus and left peritoneal specimen sent to Pathology.,38 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,38 Implantation of a dual chamber permanent pacemaker,38 " 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.",27 " Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.",38 Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. ,24 " Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. ",3 " Lumbar epidural steroid injection, L5-S1. Low back pain.",28 Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,16 " Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, ",8 MRI cervical spine.,27 The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness. ,11 Coccygeal injection,28 " 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.",7 " Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD.",21 " 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.",38 Arthroscopic procedure of the knee.,27 " Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",23 Patient with history of polyps.,38 " Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. ",27 13 years old complaining about severe ear pain - Chronic otitis media.,11 Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.,14 A 16-year-old male with Q-fever endocarditis.,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.",30 Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.,27 The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. ,26 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.,27 Normal cataract surgery. ,38 Carotid artery angiograms.,3 The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,24 Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.,39 " A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.",22 Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.,35 The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,5 EGD with dilation for dysphagia.,38 " 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.",12 " Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.",3 Brain CT and MRI - suprasellar mass (pituitary adenoma),22 A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,15 Bilateral breast MRI with & without IV contrast.,24 Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation ,3 " Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.",24 " Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.",14 " Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",38 Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,29 " The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. ",5 Consultation for jaw pain.,5 Acne with folliculitis.,8 MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.,33 " Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. ",38 " Acute appendicitis, gangrenous. Appendectomy.",14 " Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",14 " Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.",3 Diagnosis of bulbar cerebral palsy and hypotonia. ,22 Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe. ,28 2-month-old female - increased work of breathing.,3 GI Consultation for Chrohn's disease.,5 Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. ,26 Ophthalmology followup visit note.,35 " Emergent subxiphoid pericardial window, transesophageal echocardiogram.",38 Lower Extremity Arterial Doppler,33 " Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.",11 " Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.",27 " Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.",27 CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,33 Total abdominal hysterectomy (TAH) with a uterosacral vault suspension. Enlarged fibroid uterus and abnormal uterine bleeding. ,38 " Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.",5 " Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",27 Dental restorations and extractions. Dental caries. He has had multiple severe carious lesions that warrant multiple extractions at this time.,38 " Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",11 " Right knee total arthroplasty. Degenerative osteoarthritis, right knee.",27 " Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",29 " Onychomycosis present, #1 right and #1 left.",31 MRI right knee without gadolinium,33 The patient brought in by EMS with a complaint of a decreased level of consciousness.,5 Pelvic Pain and vaginal discharge,5 " Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",38 " Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.",38 Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. ,5 " Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.",38 Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,22 Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar.,38 A sample note on pre-eclampsia & eclampsia.,24 CT Brain: Midbrain hemangioma,22 " Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",39 Chronic cholecystitis without cholelithiasis.,38 2-D M-Mode. Doppler. ,3 Psychiatric Consultation of patient with dementia.,5 " Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.",38 " 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. ",2 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,38 " Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",24 " 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.",38 Laparoscopic supracervical hysterectomy. A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.,24 Trabeculectomy with mitomycin C - Sample/Template.,38 Blepharoplasty with direct brow repair.,38 Headache. Right frontal lobe glioma.,22 " Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.",11 " Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",26 Laparoscopic appendectomy. Acute appendicitis.,14 " Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. ",15 Lysis of pelvic adhesions. The patient had an 8 cm left ovarian mass. The mass was palpable on physical examination and was tender. She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.,24 MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.,33 " Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port.",3 " Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.",27 " Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.",23 " 11-year-old female. History of congestion, possibly enlarged adenoids. ",5 " A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis.",35 Antibiotic management for a right foot ulcer and possible osteomyelitis.,15 A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,12 " Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.",3 The patient was running and twisted her right ankle - right ankle sprain.,27 Bilateral lumbar sympathetic block. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored. ,28 Ruptured appendicitis.,14 Psychological Testing for ADHD,32 " Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.",23 " Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.",3 " Normal physical exam template. Well developed, well nourished, in no acute distress.",25 Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. ,8 Twin pregnancy with threatened preterm labor.,33 Occupational medicine consult with questions-answers and records review.,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,",27 " Closure of bladder laceration, during cesarean section.",38 Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,5 " 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. ",38 Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,39 MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.,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.,15 Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. ,14 " Microscopic hematuria with lateral lobe obstruction, mild.",39 " Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.",35 Osteoarthritis of the right knee. Right knee joint steroid injection.,28 Routine colorectal cancer screening. He occasionally gets some loose stools. ,5 Consultation - an 87-year-old white female with weakness and a history of polymyositis.,5 " Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. ",27 The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 " Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.",5 A male patient presented for evaluation of chronic abdominal pain.,15 One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,5 " 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. ",22 She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.,38 " A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.",33 Scleral Buckle opening under general anesthesia.,38 " History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.",15 Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,27 " Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",5 " Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",38 " Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",39 Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,38 Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,38 A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. ,22 Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.,38 " Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.",27 Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. ,14 " Patient with suspected nasal obstruction, possible sleep apnea. ",5 Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night.,22 " 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.",5 Left endoscopic carpal tunnel release and endotracheal fasciotomy.,27 Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.,27 " Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.",27 2-D Echocardiogram,33 Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,28 Headache. Right frontal lobe glioma.,5 " The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ",16 Sample post dilation patient instructions.,26 Left laparoscopic hand-assisted nephrectomy.,38 " Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",10 Prostate Brachytherapy - Prostate I-125 Implantation,16 Psychiatric History and Physical - Patient with major depression,5 Plantar Fascia Injection,28 Procedure note on Keller Bunionectomy,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. ",5 Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.,38 Patient presents with gross hematuria that started this morning.,5 Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,29 " Multiple contusions and abdominal pain, status post motor vehicle collision. ",15 " Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.",38 CT Abdomen & Pelvis W&WO Contrast,33 " Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",22 " Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.",38 " Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",3 " Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",38 " He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ",29 Incision and drainage of right buccal space abscess and teeth extraction.,7 " Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",12 " Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.",5 Complete heart block with pacemaker malfunction and a history of Shone complex.,12 The patient comes in today because of feeling lightheaded and difficulty keeping his balance.,5 Intrauterine pregnancy at term with previous cesarean. Desired sterilization. Status post repeat low transverse cesarean and bilateral tubal ligation.,24 A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,5 " Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",21 EGD with dilation for dysphagia.,14 " MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.",22 Pediatric Gastroenterology - Rectal Bleeding Consult.,14 " Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. ",39 A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.,27 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,27 " Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",16 " The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders.",5 ,5 " This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.",5 Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,35 " Trigger thumb release. Right trigger thumb. The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release). ",27 " Sample normal ear, nose, mouth, and throat exam.",25 History of right leg pain. Leg pain is no longer present.,35 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. ,35 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.,27 MRI T-spine and CXR - Aortic Dissection.,27 Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.,10 " Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.",38 " Chief complaint of chest pain, previously diagnosed with hyperthyroidism.",15 " Questionable foreign body, right nose. Belly and back pain. Mild constipation.",15 " The thoracic spine was examined in the AP, lateral and swimmer's projections.",22 " 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.",31 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,21 " Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.",38 " Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.",38 Bilateral open carpal tunnel release.,38 " Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.",28 Patient with swelling of lips and dysphagia and Arthritis.,5 " Cardiac arrest, severe congestive heart failure, acute on chronic respiratory failure, osteoporosis, and depression.",10 " Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.",38 " Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ",27 Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,38 " 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. ",38 " Pain and swelling in the right foot, peroneal tendon tear.",33 A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,15 Pain management sample progress note.,27 " Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",31 Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,38 " The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. ",3 " Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",27 Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery,5 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,23 Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. ,5 Chronic snoring in children,36 CT Scan of brain without contrast.,33 A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,22 Caudal epidural steroid injection,28 Open radical retropubic prostatectomy with bilateral lymph node dissection.,38 Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,38 " Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.",5 MRI right ankle.,27 " Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain.",33 The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.,5 " Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",10 " Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.",5 " Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.",38 " Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.",27 " Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.",16 " Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 Initial evaulation - neck and back pain.,4 " Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.",38 Sellar HCT - Pituitary mass,22 Echocardiogram and Doppler,3 Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,29 " Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.",31 " Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.",38 Patient with a history of right upper pons and right cerebral peduncle infarction.,5 " MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.",33 Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,22 " Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.",38 " Severe tonsillitis, palatal cellulitis, and inability to swallow.",5 " Exam under anesthesia with uterine suction curettage. A 10-1/2 week pregnancy, spontaneous, incomplete abortion.",24 Bilateral myringotomy tubes and adenoidectomy.,11 " Request for consultation to evaluate stomatitis, possibly methotrexate related.",5 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,22 Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,38 " Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.",23 Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones.,5 " The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ",5 Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.,38 Revision right total knee arthroplasty. Right failed total knee arthroplasty.,38 " Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 " Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",38 MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),22 " The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. ",22 Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. ,35 Ultrasound-Guided Paracentesis for Ascites,38 " Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.",23 The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,15 Patient with history of polyps.,14 " 5-month recheck on type II diabetes mellitus, as well as hypertension.",35 " Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.",14 Chronic headaches and pulsatile tinnitus.,5 A female for a complete physical and follow up on asthma with allergic rhinitis.,15 " Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.",38 Laparoscopic appendectomy. The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis.,14 " Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.",38 " Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan.",3 Patient with a 1-year history of progressive anterograde amnesia,5 " 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. ",15 " CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).",22 " Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical",5 " A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.",31 " Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.",3 Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,27 Elevated PSA with nocturia and occasional daytime frequency.,39 Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.,38 Excision of bilateral chronic hydradenitis.,38 " T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",5 Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation.,33 " Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.",38 " Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ",38 " Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",5 Cervical Selective Nerve Root Block,28 " Female with intermittent rectal bleeding, not associated with any weight loss. The patient is chronically constipated.",20 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,28 Patient with a three-day history of emesis and a four-day history of diarrhea,35 Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,38 Permacath placement - renal failure.,38 " Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.",3 Underwent tonsillectomy and adenoidectomy two weeks ago. ,11 " Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.",3 The patient is admitted with a diagnosis of acute on chronic renal insufficiency.,5 A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,14 " 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.",5 " Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",14 Incision and drainage (I&D) of buttock abscess. ,38 " The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. ",5 Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,27 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.,22 Itchy red rash on feet - Tinea Pedis,31 " Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.",14 Right nodular malignant mesothelioma.,16 Patient with right ankle pain.,31 " Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",38 The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.,35 " 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.",5 Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. ,38 " The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving.",33 Right orchiopexy and right inguinal hernia repair.,38 " Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.",5 " Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",31 " Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.",35 " Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.",11 Small office note on premature retina and vitreous.,26 " Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.",15 Right foot series after a foot injury.,33 Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,38 " Placement of Scott cannula, right lateral ventricle",23 " Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",21 " Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",38 Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,33 " Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.",15 " Patient with several medical problems - numbness, tingling, and a pain in the toes.",15 Laparoscopic right salpingooophorectomy. Right pelvic pain and ovarian mass. Right ovarian cyst with ovarian torsion.,24 Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor. ,38 " Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.",5 Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,38 Bilateral myringotomy tubes and adenoidectomy.,38 " One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well.",15 The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.,22 MRI Brain & T-spine - Demyelinating disease.,27 " Ultrasound-guided placement of multilumen central venous line, left femoral vein.",38 " Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst.",24 Excisional biopsy of right cervical lymph node.,38 Symptomatic thyroid goiter. Total thyroidectomy.,15 Colonoscopy due to hematochezia and personal history of colonic polyps.,14 Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,22 " Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.",5 Rhabdomyosarcoma of the left orbit. Left subclavian vein MediPort placement. Needs chemotherapy.,16 " Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.",39 " EGD with photos and biopsies. This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently. ",14 Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,22 Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,38 " A 44-year-old, 250-pound male presents with extreme pain in his left heel.",31 The patient needs refills on her Xanax,25 " GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.",5 " The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.",5 " Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.",38 A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. ,3 Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,5 " Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.",35 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. ,5 " Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. ",38 Patient with increased shortness of breath of one day duration.,10 CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.,22 " Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.",27 Chronic headaches and pulsatile tinnitus.,11 Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,15 " The patient is 14 months old, comes in with a chief complaint of difficulty breathing. ",12 " Well-child check sports physical - Well child asthma with good control, allergic rhinitis.",5 " Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.",5 " A 49-year-old female with ankle pain times one month, without a specific injury. ",27 MRI left knee without contrast.,33 " Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 A 60-year-old female presents today for care of painful calluses and benign lesions.,38 " Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.",22 MRI - Arteriovenous malformation with hemorrhage.,22 Laparoscopic-assisted vaginal hysterectomy. Abnormal uterine bleeding. Uterine fibroids.,24 Ultrasound Abdomen - elevated liver function tests.,14 " Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.",38 " The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.",22 Patient was found to have decrease in mental alertness,15 Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy.,38 Right subclavian Port-a-Cath insertion in a patient with bilateral breast carcinoma. ,38 " 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.",16 Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.,33 " Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.",38 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. ,15 " A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.",10 " Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.",38 " Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.",39 " Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.",38 The patient was referred for evaluation of cataracts bilaterally,20 Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. ,33 " Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable.",3 " 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. ",5 Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,22 Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.,3 " 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.",27 Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.,38 " Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.",24 Death summary of an 80-year-old patient with a history of COPD.,10 " Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.",15 Consultation for evaluation of thrombocytopenia.,5 Blepharoplasty procedure,26 " Patient with hypertension, dementia, and depression.",5 " Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.",38 A 66-year-old female with knee osteoarthrosis who failed conservative management.,10 " Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. ",14 " Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.",23 Dietary consultation for carbohydrate counting for type I diabetes.,9 Left shoulder pain. Evaluate for rotator cuff tear.,33 Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,26 " Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.",11 Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.,3 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.,33 " 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.",38 Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,14 Traumatic injury to bilateral upper extremities. Dressing change under anesthesia. This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change.,38 " Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.",5 Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,38 MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.,22 Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 " Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.",35 " Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.",38 " MRI of the Cervical, Thoracic, and Lumbar Spine",22 HDR Brachytherapy,33 An example/template for a routine normal female physical exam.,25 " Sample normal ear, nose, mouth, and throat exam.",11 An example/template for a routine normal male ROS.,15 Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative.,3 Revision and in situ pinning of the right hip.,27 Difficulty with both distance vision and with fine print at near.,5 Right subclavian triple lumen central line placement,3 Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%,33 Sample/template for a normal male multisystem exam.,25 " Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.",27 Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,22 " Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. ",3 Diagnosis of benign rolandic epilepsy.,20 Pain and swelling in the right foot.,27 Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. ,16 " Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.",3 Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. ,7 " Nausea, vomiting, diarrhea, and fever.",15 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,23 Laparoscopic cholecystectomy.,14 " CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",33 " 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.",5 A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,16 " Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",27 " Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid.",38 Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 Patient with confusion and hallucinations.,15 Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.,5 " 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.",14 Bilateral reduction mammoplasty for bilateral macromastia,38 Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm.,22 Right radical nephrectomy and assisted laparoscopic approach.,38 " Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.",38 Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.,33 " Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.",38 " Irritable baby, 6-week-old, with fever for approximately 24 hours.",29 Left excisional breast biopsy due to atypical ductal hyperplasia of left breast.,38 MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,22 Inguinal hernia hydrocele repair.,39 " Exploratory laparotomy, lysis of adhesions, and right hemicolectomy. Right colon cancer, ascites, and adhesions.",38 No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,3 " Hematemesis in a patient with longstanding diabetes. Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis. Mallory-Weiss tear, successful BICAP cautery. ",14 " Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.",38 Patient presents with gross hematuria that started this morning.,39 Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,3 " The patient is 14 months old, comes in with a chief complaint of difficulty breathing. ",3 Laparoscopic cholecystectomy. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,38 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.,5 " 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.",5 " A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides.",5 Colonoscopy to screen for colon cancer,38 Common description of EGD.,38 2-D Echocardiogram,3 Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,21 Invasive carcinoma of left breast. Left modified radical mastectomy.,16 " Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.",24 Nephrology office visit for followup of microscopic hematuria.,25 A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,12 Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.,33 Excisional breast biopsy with needle localization. The skin overlying the needle tip was incised in a curvilinear fashion. ,38 " Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",15 Lumbar puncture with moderate sedation.,38 Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.,11 Right middle ear exploration with a Goldenberg TORP reconstruction.,11 " A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.",5 Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction.,38 Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The patient is a 78-year-old female with back pain referring into the left side. ,28 " A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. ",22 " Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",38 Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,38 " 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.",23 " The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.",5 Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,12 " Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.",26 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.,5 Consultation for right shoulder pain.,5 " Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.",22 " Malignant mass of the left neck, squamous cell carcinoma. Left neck mass biopsy and selective surgical neck dissection, left.",38 Quick note on tachypnea.,25 " Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",31 Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,38 Neurologic consultation and follow-up.,22 Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,5 Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. ,16 " 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.",38 Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 The patient is brought in by an assistant with some of his food diary sheets.,35 " Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.",24 Consult for prostate cancer,39 Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.,21 Noncontrast CT abdomen and pelvis per renal stone protocol.,33 " History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.",22 Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,3 " Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.",12 " Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.",23 " Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",29 " Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left. ",38 Right foot series after a foot injury.,31 " Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.",27 Common Excretory Urogram - IVP template,39 " Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.",15 " 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.",15 Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. ,2 " Right shockwave lithotripsy, cystoscopy, and stent removal x2.",21 The patient with a recent change in bowel function and hematochezia.,38 " Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.",27 Unilateral transpedicular T11 vertebroplasty.,38 " Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.",38 " Autologous iliac crest bone graft to maxilla and mandible under general anesthetic. Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.",38 Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,3 Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis. ,38 " The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.",5 Full-mouth extraction of teeth and alveoloplasty in all four quadrants.,38 Patient with a past medical history of hypertension for 15 years.,15 Echocardiogram was performed including 2-D and M-mode imaging.,3 Central line insertion. Empyema thoracis and need for intravenous antibiotics.,38 " Repeat low-transverse cesarean section via Pfannenstiel incision. Intrauterine pregnancy at 39 and 1/7th weeks. Previous cesarean section, refuses trial of labor. Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.",24 " Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,38 " Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.",24 " Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.",27 " Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",38 " Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.",3 " Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.",16 " Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.",3 Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,38 Patient being referred for evaluation of glaucoma.,20 " Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. ",3 Left retrosigmoid craniotomy and excision of acoustic neuroma.,38 " Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.",38 Examination due to blood-borne pathogen exposure.,15 " Sample normal ear, nose, mouth, and throat exam.",25 Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex.,38 " Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.",15 Common CT C-Spine template,33 " Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.",38 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.,15 ,5 " CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",38 Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. ,2 " C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.",23 Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,3 Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.,3 Duplex ultrasound of legs,3 " Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",38 Frontal and lateral views of the hip and pelvis.,33 " Counting calorie points, exercising pretty regularly, seems to be doing well",9 " Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. ",35 Problem of essential hypertension. Symptoms that suggested intracranial pathology.,3 Circumcision procedure (neotal),39 Bilateral reduction mammoplasty for bilateral macromastia,6 Left temporal craniotomy and removal of brain tumor.,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. ",13 " Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",15 " Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.",22 " Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.",11 This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,5 Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms.,22 Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound.,27 Bilateral inguinal hernia. Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,39 " Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.",24 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. ,16 NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.,38 " Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",10 A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,5 " Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",35 " Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.",33 Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.,3 Myocardial perfusion imaging - patient had previous abnormal stress test. Stress test with imaging for further classification of CAD and ischemia.,3 " Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.",10 CT of Brain - Subacute SDH.,33 Discharge summary of a patient with a BRCA-2 mutation.,16 " 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.",5 " Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",38 CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.,27 " Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",33 Concomitant chemoradiotherapy for curative intent patients.,16 Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.,27 A 9-month well-child check.,5 Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 " Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",5 " A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",11 Superior labrum anterior and posterior lesion repair.,27 Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.,14 " Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.",3 " Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. ",38 " Total abdominal hysterectomy.. Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.",38 1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.,15 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 Bender-Gestalt Neurological Battery and Beck testing.,32 " Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction.",3 Autopsy - Asphyxia due to ligature strangulation.,1 Repair of ruptured globe with repositing of uveal tissue - Sample/Template.,26 " Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.",28 MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).,22 " 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.",38 The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails. ,31 Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.,33 a pleasant 62-year-old male with cerebral palsy,22 " A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides.",15 Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.,39 Caudal epidural steroid injection without fluoroscopy.,28 " Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.",35 MRI T-spine and CXR - Aortic Dissection.,22 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,38 The patient was referred due to a recent admission for pseudoseizures.,32 This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,24 " A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.",15 Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved. ,5 Bronchoscopy. Atelectasis and mucous plugging.,38 " 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. ",15 Cystopyelogram and laser vaporization of the prostate.,38 Common description of EGD,14 " Questionable foreign body, right nose. Belly and back pain. Mild constipation.",29 " Desire for sterility. Vasectomy. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.",38 Stroke in distribution of recurrent artery of Huebner (left),22 Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,27 Patient was found to have decrease in mental alertness,5 ,38 Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.,5 Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition.,5 Sample/template for a normal male multisystem exam.,15 Normal vasectomy,38 Acute appendicitis with perforation. Laparoscopic appendectomy. A CT scan of abdomen showed evidence of appendicitis with perforation. ,14 Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,33 " Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.",22 " CT abdomen without contrast and pelvis without contrast, reconstruction.",33 " History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.",14 " Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.",38 Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.,3 " The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.",5 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,27 " Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",38 " Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.",3 Laparoscopic right radical nephrectomy due to right renal mass.,21 Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,11 Endovascular Brachytherapy (EBT),33 Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.,15 " Melena and solitary erosion over a fold at the GE junction, gastric side.",14 " Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. ",37 Thallium stress test for chest pain.,3 " 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.",31 " 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.",11 " Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.",15 " 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.",3 " Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.",11 A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,15 Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.,28 Left knee arthroscopy with lateral capsular release.,38 " Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.",3 " Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",11 Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. ,5 " Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",3 " Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",38 " The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions.",37 Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,23 Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 " Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.",35 " Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.",27 " Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.",15 " Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.",27 " HCT: SAH, Contusion, Skull fracture",33 " CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",33 Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,3 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,3 " A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.",14 " L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.",23 A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,33 " Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.",23 She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.,24 Hyperfractionation. This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. ,16 Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,15 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. ,33 Insertion of central venous line and arterial line and transesophageal echocardiography probe.,38 " Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.",3 " There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. ",15 " Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",33 " A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",32 " Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. ",5 " Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",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.",22 " Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.",38 A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.,38 The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.,5 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,38 " The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.",5 Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess.,38 Circumcision and release of ventral chordee.,38 Patient dropped a weight on the dorsal aspects of his feet.,12 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. ,23 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.,33 " HCT: SAH, Contusion, Skull fracture",22 " Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",23 " Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability.",38 Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,14 Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.,25 Qualified medical evaluation report of a patient with back pain.,4 Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.,18 Patient with palpitations and rcent worsening of chronic chest discomfort.,3 " Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.",38 " A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 " 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. ",27 " Esophagogastroduodenoscopy, photography, and biopsy. Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.",14 Elevated cholesterol and is on medication to lower it.,5 A 2-month-old female with 1-week history of congestion and fever x2 days.,5 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,38 A 34-year old female with no fetal heart motion noted on office scan.,33 Lumbar puncture with moderate sedation.,23 Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.,27 " Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid.",24 " 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. ",39 " Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension.",10 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.,27 Open reduction and internal fixation of left tibia.,38 Repeat cesarean section and bilateral tubal ligation.,38 " Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. ",3 Elevated cholesterol and is on medication to lower it.,9 Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.,3 " Right open carpal tunnel release and cortisone injection, left carpal tunnel.",38 Esophagogastroduodenoscopy and colonoscopy with polypectomy,38 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.,38 " Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",38 " Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.",38 " 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.",13 " Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",5 Patient with a diagnosis of stroke.,15 " A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. ",3 " Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.",38 " Intercostal block from fourth to tenth intercostal spaces, left. Chest pain secondary to fractured ribs, unmanageable with narcotics.",28 " A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" ",5 Circumcision procedure in a baby,39 " Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.",3 AP abdomen and ultrasound of kidney.,33 Vaginal discharge with a foul odor.,12 " Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ",24 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,15 " 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. ",38 Diagnosis of bulbar cerebral palsy and hypotonia. ,20 A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,10 MRI Elbow - A middle-aged female complaining of elbow pain.,33 Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,28 " Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.",16 " Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. ",39 Evaluation and recommendations regarding facial rhytids.,8 Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.,38 Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition.,24 Patient presents for treatment of suspected rheumatoid arthritis.,34 This patient has reoccurring ingrown infected toenails.,35 A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,24 MRI Brain: Subacute right thalamic infarct.,22 " 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.",27 Tracheotomy for patient with respiratory failure.,38 Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,27 " Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.",27 " Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.",38 " Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",26 " 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. ",22 Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.,38 Discharge summary of a patient with mood swings and oppositional and defiant behavior.,10 Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,14 Patient with morbid obesity.,15 Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar.,33 " Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.",38 Well-child check and school physical.,29 Dobutrex stress test for abnormal EKG,3 Left laparoscopic hand-assisted nephrectomy.,21 " Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.",23 " Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",38 Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,32 Completion thyroidectomy with limited right paratracheal node dissection.,38 " Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr. 7. Microscopic dissection.",23 Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome.,27 " Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.",24 Left endoscopic carpal tunnel release and endotracheal fasciotomy.,38 Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,38 Diagnostic cerebral angiogram and transcatheter infusion of papaverine,22 Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,3 Sports physical with normal growth and development.,5 Sample female physical exam.,15 " 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.",5 " Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",38 Normal cataract surgery. ,26 " Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.",26 " Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.",38 Common CT Facial template.,33 " Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.",39 Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,22 " 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.",16 " Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",15 Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night.,5 Coil embolization of patent ductus arteriosus.,38 " Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 Repair of bilateral cleft of the palate with vomer flaps.,11 " Upper endoscopy, patient with dysphagia.",38