Unnamed: 0 int64 8 5k | description stringlengths 17 433 | medical_specialty stringlengths 8 30 | sample_name stringlengths 5 60 | narrative stringlengths 286 15.2k | keywords stringlengths 1 914 ⌀ | narrative_length int64 38 2.46k |
|---|---|---|---|---|---|---|
1,185 | Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region. | Surgery | Bifrontal Cranioplasty | PREOPERATIVE DIAGNOSIS:, Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR ... | surgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal, | 401 |
3,223 | Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. | General Medicine | Pneumoconiosis | HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time, he is admitted for continued,manag... | null | 447 |
682 | Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter. | Surgery | Internal Jugular Vein Catheter Insertion | PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.... | surgery, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein | 333 |
130 | Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream. | Urology | Elevated PSA - H&P | CHIEF COMPLAINT:, This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 mon... | null | 574 |
2,626 | Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. | Obstetrics / Gynecology | Delivery Note - 3 | DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal deli... | obstetrics / gynecology, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality ... | 184 |
4,056 | Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy | Cosmetic / Plastic Surgery | Nipple Reconstruction | PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a fu... | cosmetic / plastic surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, a... | 598 |
4,211 | Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features. | Consult - History and Phy. | OB/GYN Consultation - 1 | PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:, Prozac 20 mg q.d. She desires to be on the NuvaRing.,ALLERGIES:, Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:, VITALS: Stable. Weight: 114 lb. Height: 5 feet 2 inches. ... | consult - history and phy., gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade, | 264 |
3,865 | 2-month-old female - increased work of breathing. | Emergency Room Reports | Bronchiolitis - 2-month-old | CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night... | null | 766 |
3,356 | Nausea, vomiting, diarrhea, and fever. | General Medicine | Gen Med Consult - 27 | CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought... | 410 | |
1,152 | Brachytherapy, iodine-125 seed implantation, and cystoscopy. | Surgery | Brachytherapy | PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63. Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male... | surgery, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate, | 574 |
195 | Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally. | Surgery | Vein Stripping | PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 inc... | surgery, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous, | 493 |
828 | Esophagogastroduodenoscopy with photo. Insertion of a percutaneous endoscopic gastrostomy tube. Neuromuscular dysphagia. Protein-calorie malnutrition. | Surgery | Esophagogastroduodenoscopy & Gastrostomy Tube Insertion | PREOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1. Esophagogastroduodenoscopy with photo.,2. Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:, IV se... | surgery, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube, | 361 |
4,995 | 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. | Allergy / Immunology | Kawasaki Disease - Discharge Summary | ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, 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 ne... | allergy / immunology, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin | 270 |
2,703 | Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome. | Neurosurgery | Frontotemporoparietal Craniotomy | PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED: ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: ... | neurosurgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma, | 402 |
2,567 | 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. | Obstetrics / Gynecology | Low-Transverse C-Section & BTL - 1 | PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent st... | null | 862 |
4,900 | 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. | Cardiovascular / Pulmonary | Cardiolite Treadmill Stress Test | CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:, This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:, 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 ... | cardiovascular / pulmonary, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill, | 197 |
2,167 | 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. | Orthopedic | Lower back pain | HISTORY OF PRESENT ILLNESS:, Patient is a 50-year-old white male complaining of continued lower back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after wh... | orthopedic, back pain, lumbar muscle strain, chronic back pain, illness, lower, medications, | 809 |
2,782 | Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. | Neurology | Suspected Seizure Activity | XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. He is requesting to come off the Dilantin a... | neurology, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed ... | 176 |
4,864 | 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. | Cardiovascular / Pulmonary | Consult - Abnormal EKG | REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient... | null | 466 |
1,378 | Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea. | SOAP / Chart / Progress Notes | Gen Med SOAP | SUBJECTIVE: , This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was someth... | soap / chart / progress notes, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety, | 739 |
3,923 | Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency. | Discharge Summary | Goldenhar Syndrome - Discharge Summary | ADMITTING DIAGNOSES,1. Vomiting, probably secondary to gastroenteritis.,2. Goldenhar syndrome.,3. Severe gastroesophageal reflux.,4. Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1. Gastroenteritis versus bowel obstruction.,2. Gastroesophageal reflux.,3. Goldenhar syndrome.,4. Anemia,... | null | 553 |
3,671 | 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. | Gastroenterology | Barium Swallow Study Evaluation | HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her 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 ch... | gastroenterology, globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods, | 459 |
4,351 | 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. | Consult - History and Phy. | Glioblastoma Multiforme - Consult | REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our... | null | 338 |
604 | Repair of upper lid canalicular laceration - Sample/Template. | Surgery | Lid Laceration Repair | PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMEN... | surgery, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid ca... | 276 |
4,674 | Complete heart block with pacemaker malfunction and a history of Shone complex. | Cardiovascular / Pulmonary | Shone complex | HISTORY AND PHYSICAL: ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block. He is on the pacemaker. He had a coarctation of the aorta and that was repaired when he was an infant. He was followed in our Cardiology Clinic here and has been doing well. However last night, h... | null | 717 |
712 | 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. | Surgery | Hysteroscopy & Laproscopy with Salpingooophorectomy | PREOPERATIVE DIAGNOSES:,1. Thickened endometrium and tamoxifen therapy.,2. Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1. Thickened endometrium and tamoxifen therapy.,2. Adnexal cyst.,3. Endometrial polyp.,4. Right ovarian cyst.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,3. Laparoscopy w... | surgery, adnexal cyst, endometrial, ovarian cyst, dilation and curettage, d&c, hysteroscopy, laparoscopy, salpingooophorectomy, aspiration of cyst fluid, thickened endometrium, tamoxifen therapy, abdominal wall, cyst, ovarian, endometrium, | 657 |
3,106 | Chiropractic IME with answers to questions from Insurance Company. | IME-QME-Work Comp etc. | Chiropractic IME - 1 | P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and th... | null | 1,643 |
3,312 | Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity. | General Medicine | Gen Med Progress Note - 12 | SUBJECTIVE: , The patient was seen and examined. He feels much better today, improved weakness and decreased muscular pain. No other complaints.,PHYSICAL EXAMINATION:,GENERAL: Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS: Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.... | general medicine, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure, | 241 |
933 | 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. | Surgery | Cystourethroscopy & TURP - 1 | PREOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA:, Spinal.,RESECTION TIME:, Less than one hour.,INDICA... | surgery, urinary retention, transurethral resection of prostate, prostate, enlarged, obstructive voiding symptoms, benign prostate hypertrophy, ureteral orifices, prostate hypertrophy, cystourethroscopy, turp, hypertrophy, resectoscope, urinary, bladder, resection, | 355 |
3,111 | 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. | Hospice - Palliative Care | Care Conference With Family | REASON FOR FOLLOWUP:, 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.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient ... | hospice - palliative care, full code status, terminal wean, comfort care, cpr, advanced cardiac life support, care conference, family, bedsideNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy an... | 432 |
4,798 | 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. | Cardiovascular / Pulmonary | Flexible Fiberoptic Bronchoscopy -1 | POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbro... | cardiovascular / pulmonary, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx, | 580 |
3,774 | Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear. | ENT - Otolaryngology | Cleft Repair - Soft Palate | PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1. Repair of cleft soft palate, CPT 42200.,2. Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table. After anesthesia was ... | ent - otolaryngology, repair, tragus, oral mucosa, nasal mucosa, ear tag, soft palate, palate, cleft, soft | 363 |
4,863 | Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale. | Cardiovascular / Pulmonary | Coarctation of Aorta | HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicu... | cardiovascular / pulmonary, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen, | 785 |
1,282 | 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. | Speech - Language | Speech Therapy - Discharge Summary - 2 | The patient made some progress during therapy. She accomplished two and a half out of her five short-term therapy goals. We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits. The patient improved on her turn taking skills during con... | speech - language, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy... | 181 |
907 | 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. | Surgery | Diagnostic Arthroscopy | PREOPERATIVE DIAGNOSIS:, Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Torn rotator cuff, right shoulder.,2. Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with subacromial decompression.,2. Open repair of rotator cuff using three Panalok... | surgery, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial, | 585 |
3,237 | Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter. | General Medicine | Normal ROS Template - 3 | HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm... | general medicine, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling, | 154 |
4,305 | Consult for laparoscopic gastric bypass. | Consult - History and Phy. | Laparoscopic Gastric Bypass Consult - 1 | HISTORY OF PRESENT ILLNESS: , I have seen ABC today. He is a very pleasant gentleman who is 42 years old, 344 pounds. He is 5'9". He has a BMI of 51. He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. He is pursuing surgical attempts of weight loss to fee... | consult - history and phy., laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight, | 716 |
2,139 | MRI left knee without contrast. | Orthopedic | MRI Knee - 1 | EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the late... | orthopedic, collateral ligament, mri, knee, collateral, sprain, medial, ligament, | 162 |
2,301 | 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. | Orthopedic | Bunionectomy - Austin - Akin | PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformi... | orthopedic, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy | 839 |
2,262 | CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. | Orthopedic | CT Head, Facial Bones, Cervical Spine | EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:, A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Addition... | orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical | 411 |
3,501 | 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. | Gastroenterology | Laparoscopic Cholecystectomy - 4 | PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute cholecystitis.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS: , None.,PROCEDURE: ,The patient was taken to the operating room, and after obtaining adequate general a... | gastroenterology, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder | 276 |
4,536 | To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG. | Consult - History and Phy. | Cardiac Consultation - 2 | CHIEF REASON FOR CONSULTATION:, Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:, This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath... | null | 432 |
2,820 | MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old. | Neurology | MRI of Brain w/o Contrast. | EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE: ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age. There are no... | neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast, | 110 |
1,460 | Chronic snoring in children | Sleep Medicine | Snoring | CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome. Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardi... | sleep medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistant ... | 134 |
4,029 | Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T. | Dentistry | Teeth Extraction & I&D - 2 | PREOPERATIVE DIAGNOSIS:, Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:, General, oral endotracheal tube.,COMPLICATIONS: , ... | dentistry, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess | 284 |
2,019 | 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. | Orthopedic | Ulnar Nerve Transposition | PROCEDURE:, Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , 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.,A curvilinear incision w... | orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve | 250 |
775 | Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms. | Surgery | Gastroscopy - 2 | PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosi... | surgery, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation | 190 |
3,275 | Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter. | General Medicine | Lymphoblastic Leukemia - Consult | CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient w... | null | 1,112 |
272 | Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear. | Surgery | Tonsillectomy & Adenoidectomy | PREOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:, Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:, General.,HIS... | surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids | 394 |
1,606 | MRI Brain, Carbon Monoxide poisoning. | Radiology | MRI Brain - CO poisoning | CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next rememb... | null | 273 |
3,121 | 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. | Hematology - Oncology | Sickle Cell Anemia - ER Visit | HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a room mate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies an... | null | 483 |
3,068 | 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. | Letters | Pediatric - Letter | Sample Address,RE: Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing, cough and shortness of breath over... | letters, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma, | 294 |
3,990 | Dietary consultation for diabetes during pregnancy. | Diets and Nutritions | Dietary Consult - Diabetes - 1 | SUBJECTIVE:, This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back... | diets and nutritions, diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks | 663 |
4,034 | 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. | Dentistry | ORIF Mandibular Fracture & Dental Implant Removal | PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular frac... | dentistry, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant, | 722 |
3,993 | Elevated cholesterol and is on medication to lower it. | Diets and Nutritions | Dietary Consult - 1 | SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has sta... | diets and nutritions, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol | 314 |
End of preview. Expand in Data Studio
- Downloads last month
- 8