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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 |
1,244 | Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope. | Surgery | Anterior Cervical Discectomy & Fusion - 6 | PREOPERATIVE DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1. Anterior cervical discectomy with decompression of spinal cord C7-T1.,2. Anterior cervical fusion, C7-T1.,3. Anterior cervical instrumentation, anterior C7-T1.,4. Insertion of... | surgery, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation, | 387 |
951 | Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder. | Surgery | Cystopyelogram - 1 | PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS: ,Gross hematuria.,OPERATIONS: ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS: ,Significant amount of bladder clots measuring about 150... | surgery, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots, | 475 |
381 | Acute lymphocytic leukemia in remission, removal of venous port. | Surgery | Removal of Venous Port | PREOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,POSTOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,OPERATION PERFORMED: ,Removal of venous port.,ANESTHESIA: , General.,INDICATIONS: , This 9-year-old young lady presented with ALL in Orange County and had a port placed at that time. ... | surgery, removal of venous port, acute lymphocytic leukemia, venous port, lymphocytic, leukemia, venous | 186 |
3,801 | 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. | Endocrinology | Axillary Dissection & Mass Excision | PREOPERATIVE DIAGNOSIS:, Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS: ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1. Left axillary dissection with incision and drainage of left axillary mass.,2. Right axillary mass excision and ... | endocrinology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary, | 646 |
8 | Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs. | Bariatrics | Lipectomy - Abdomen/Thighs | PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:, Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:, General.,FINDINGS AND PROCEDURE:, With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks... | bariatrics, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs, | 243 |
1,204 | 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. | Surgery | Arthroscopy, Meniscoplasty, & Chondroplasty | PREOPERATIVE DIAGNOSIS:, Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1. Arthroscopy of the left knee.,2. Left arthroscopic medial meniscoplasty of medial femoral condyle.,3. Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: ,... | surgery, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral | 458 |
2,898 | 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. | Neurology | EMG/Nerve Conduction Study - 2 | HISTORY: , The patient is a 78-year-old right-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. She was undergoing a spinal epidural injection about a month ago and had worsening of r... | neurology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/ner... | 280 |
4,627 | Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema. | Cardiovascular / Pulmonary | Tracheostomy Change | PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDI... | cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator | 427 |
1,662 | CT of abdomen with and without contrast. CT-guided needle placement biopsy. | Radiology | CT-Guided Needle Placement Biopsy | EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Seve... | radiology, ct, ct-guided, ct-guided biopsy, hounsfield units, mri, abdomen, biopsy, cholecystectomy, contrast, contrast administration, decubitus position, images, needle, postcontrast, renal lesions, renal mass, renal tumor, with and without, ct guided needle placement, ct of abdomen, needle placement, lower pole, ct ... | 322 |
17 | Patient status post lap band placement. | Bariatrics | Lap Band Adjustment | REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of ... | bariatrics, lap band adjustment, lap band placement, lap band, | 230 |
4,471 | Patient presents for a colostomy reversal as well as repair of an incisional hernia. | Consult - History and Phy. | Consult for Colostomy Reversal | CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital wi... | null | 708 |
3,171 | 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. | Hematology - Oncology | Craniopharyngioma - Postop | REASON FOR VISIT:, Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:, Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, u... | hematology - oncology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma, | 243 |
4,021 | 1+ year, black female for initial evaluation of a lifelong history of atopic eczema. | Dermatology | Atopic Eczema | SUBJECTIVE:, This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working no... | dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel, | 175 |
779 | 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 w... | Surgery | Foreign Body Removal - Foot | PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.... | surgery, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound, | 842 |
865 | Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty. | Surgery | Endoscopic Sinus Surgery | PREOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertroph... | null | 735 |
3,868 | Mother states he has been wheezing and coughing. | Emergency Room Reports | Asthma in a 5-year-old | CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asth... | null | 390 |
922 | 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. | Surgery | Debridement Necrotic Tissue | PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:, Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:, Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area... | surgery, debridement, abdomen, peritoneal, pannus, pathology, necrotizing infection, necrotic tissue, tissue, infection, necrotizing, groin, wound, | 746 |
2,155 | Patient with right ankle pain. | Orthopedic | MRI Ankle - 1 | EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28... | null | 650 |
4,795 | 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 b... | Cardiovascular / Pulmonary | Flexible Fiberoptic Bronchoscopy | PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. ... | cardiovascular / pulmonary, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronch... | 564 |
1,475 | A sample note on Rheumatoid Arthritis | Rheumatology | Rheumatoid Arthritis | RHEUMATOID ARTHRITIS, (or RA) is a chronic, systemic condition with primary involvement of the joints. Joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue. Specifically, the tissues lining the joint are involved as well as cartilage and muscle and sometimes the ey... | rheumatology, ra, rheumatoid arthritis, joint inflammation, swollen joints, arthritis, joints, inflammation, corticosteroids, rheumatoid, | 419 |
580 | Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid. | Surgery | Low-Transverse C-Section - 4 | PREOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,OPERATION:, Primary low-transverse C-section.,ANESTHESIA:, Epidural.,DESCRIPTION OF OPERATION: ... | surgery, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision, | 364 |
1,943 | Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter. | Pediatrics - Neonatal | Broviac Catheter Placement | PREOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,ANESTHESIA:, General.,PROCEDURE:, Placement of left subclavian 4-French Broviac catheter.,INDICATIONS: ,The patient is... | pediatrics - neonatal, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous, | 429 |
890 | Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort. | Surgery | Dupuytren Disease Excision | PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS: ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED: ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS: ,Non... | surgery, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger | 245 |
1,645 | Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms. | Radiology | EMG/Nerve Conduction Study - 6 | HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and ... | radiology, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles, | 284 |
4,655 | Emergent subxiphoid pericardial window, transesophageal echocardiogram. | Cardiovascular / Pulmonary | Subxiphoid Pericardial Window | PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxipho... | cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic | 224 |
3,975 | Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus. | Discharge Summary | D&C - Discharge Summary | ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,OPERATIONS PERFORMED:,1. Hysteroscopy.,2. Dilatation and curettage (D&C).,3.... | discharge summary, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid, | 260 |
2,390 | Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen. | Ophthalmology | Rhytidectomy & Blepharoplasty | PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous ... | ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral ble... | 751 |
4,617 | 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. | Cardiovascular / Pulmonary | Transthoracic Echocardiography | REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricu... | cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic | 179 |
783 | Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle. | Surgery | Foreign Body Removal - Thigh | PREPROCEDURE DIAGNOSIS:, Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE: ,Removal of foreign body of right thigh.,HISTORY: ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh. The patient comes with an ul... | surgery, removal of foreign body, sewing needle, foreign body | 222 |
1,930 | Questionable foreign body, right nose. Belly and back pain. Mild constipation. | Pediatrics - Neonatal | Foreign Body - Right Nose | CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels... | 576 | |
3,361 | A 12-year-old young man with sinus congestion. | General Medicine | Gen Med Consult - 22 | SUBJECTIVE:, This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently.,CURRENT MEDICATIONS:, ... | general medicine, allergic rhinitis, sinus infection, sinus congestion, congestion, sinus | 183 |
854 | Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping. | Surgery | Epidurogram | PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION... | surgery, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle | 233 |
3,714 | Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally. | ENT - Otolaryngology | Septoplasty & Turbinectomy | OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy... | ent - otolaryngology, sinusitis, ktp laser, septoplasty, deviated, endoscopy, ethmoidectomy, hypertrophied, maxillary, nasal obstruction, nasal septum, sinus, turbinates, turbinectomy, partial ethmoidectomy, parker knife, sinus ostium, nasal cavity, maxillary sinus, ktp, mucosa, cavity, forceps, antrostomies, ostium, n... | 436 |
2,986 | Psychosocial Evaluation of patient before kidney transplant. | Nephrology | Psychosocial Eval for Kidney Transplant | HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is... | null | 455 |
245 | 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. | Surgery | Tracheostomy | PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible b... | surgery, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cann... | 854 |
16 | Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube. | Cardiovascular / Pulmonary | Tracheostomy | PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible b... | cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy,... | 854 |
1,507 | Ultrasound Abdomen - elevated liver function tests. | Radiology | Ultrasound - Abdomen - 1 | EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of th... | radiology, aorta, dilated common duct, mrcp, ercp, elevated liver function tests, pancreatic duct, distended bladder, ultrasound abdomen, cholecystectomy, ultrasound, abdomen, liver, dilatation, caliectasis, kidney, bladder, duct | 152 |
724 | Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given. | Surgery | Hydrocelectomy | PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose... | surgery, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles, | 357 |
4,181 | A white female presents for exam and Pap. | Consult - History and Phy. | Physical Exam and Pap - 1 | SUBJECTIVE:, This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap. Last Pap was a year ago and normal. LMP was 08/29/2004. Her cycles are usually regular, although that one came about a week early. Her husband has had a vasectomy. Overall, she is feeling well.,Health history form was r... | null | 483 |
2,082 | 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. | Orthopedic | Osteotomy & Bunionectomy | PREOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1. D... | 1,137 | |
1,568 | Left shoulder pain. Evaluate for rotator cuff tear. | Radiology | MRI Shoulder - 1 | EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:, Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. O... | radiology, rotator cuff tear, cuff tear, rotator cuff, joint, mri, rotator, cuff, shoulder, tear, | 70 |
1,563 | MRI of the Cervical, Thoracic, and Lumbar Spine | Radiology | MRI Spine | INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal. At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise. At C5-C6, there were minimal diffuse disc bulge and uncovertebral ost... | radiology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference p... | 267 |
1,489 | Whole body radionuclide bone scan due to prostate cancer. | Radiology | Whole Body Radionuclide Bone Scan | INDICATION:, Prostate Cancer.,TECHNIQUE:, 3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections.,FINDINGS:, There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull. The u... | radiology, prostate cancer, technetium, whole body, urinary retention, bone scan, radionuclide, | 115 |
2,781 | 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. | Neurology | Physical Therapy - Brain Tumor Removal | DIAGNOSIS:, Status post brain tumor removal.,HISTORY:, The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical thera... | null | 493 |
2,098 | 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. | Orthopedic | ORIF & Cervical Fusion | PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS: ,Fracture dislocation, C2.,OPERATION PERFORMED,1. Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2. Posterior spinal instrumentation C1-C3, using Synthes system.,3. Posterior cervical fusion C1-C3.,4. Insertion of ... | orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation, | 821 |
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