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1,400 | Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. | SOAP / Chart / Progress Notes | Foot Lesions | S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first me... | soap / chart / progress notes, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful |
1,401 | Evaluation and recommendations regarding facial rhytids. | SOAP / Chart / Progress Notes | Facial Rhytids | HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial f... | soap / chart / progress notes, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: 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 r... |
1,402 | Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively. | SOAP / Chart / Progress Notes | Followup Screw Fixation | REASON FOR VISIT: ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old gentleman who is now approximately 4 months status post perc... | soap / chart / progress notes, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal |
1,403 | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | SOAP / Chart / Progress Notes | Dietary Consult - Weight Reduction | SUBJECTIVE:, This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendation... | soap / chart / progress notes, hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food |
1,404 | Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection. | SOAP / Chart / Progress Notes | E. Coli UTI - Followup | HISTORY OF PRESENT ILLNESS:, The patient presents today for followup, recently noted for E. coli urinary tract infection. She was treated with Macrobid for 7 days, and only took one nighttime prophylaxis. She discontinued this medication to due to skin rash as well as hives. Since then, this had resolved. Does not... | soap / chart / progress notes, urinary tract infection, escherichia coli, prophylactic macrodantin, e. coli, infection, |
1,405 | Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. | SOAP / Chart / Progress Notes | Endometrial Cancer Followup | CHIEF COMPLAINT:,1. Stage IIIC endometrial cancer.,2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with t... | soap / chart / progress notes, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease, |
1,406 | Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. | SOAP / Chart / Progress Notes | Erectile Dysfunction - Followup | HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or ... | soap / chart / progress notes, improvement of erectile dysfunction, erectile dysfunction, erectile, dysfunction, cialis, psa, biopsy, |
1,407 | A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis. | SOAP / Chart / Progress Notes | Down's syndrome | SUBJECTIVE:, This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also found that he was hypothyroid with ele... | soap / chart / progress notes, down’s syndrome, hypothyroidism, onychomycosis, hypothyroid, tsh, down’s |
1,408 | Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome | SOAP / Chart / Progress Notes | Dietary Consult - Hyperlipidemia | SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was... | soap / chart / progress notes, hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight |
1,409 | The patient is brought in by an assistant with some of his food diary sheets. | SOAP / Chart / Progress Notes | Dietary Consult - 3 | SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went o... | soap / chart / progress notes, weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food |
1,410 | Dietary consultation for gestational diabetes. | SOAP / Chart / Progress Notes | Dietary Consult - Gestational Diabetes | SUBJECTIVE:, This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with ... | soap / chart / progress notes, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning |
1,411 | Counting calorie points, exercising pretty regularly, seems to be doing well | SOAP / Chart / Progress Notes | Dietary Consult - 4 | SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. Th... | soap / chart / progress notes, overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly |
1,412 | Dietary consultation for diabetes during pregnancy. | SOAP / Chart / Progress Notes | 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... | soap / chart / progress notes, diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks |
1,413 | The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. | SOAP / Chart / Progress Notes | Dietary Consult - 2 | SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food d... | soap / chart / progress notes, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food |
1,414 | Patient today with ongoing issues with diabetic control. | SOAP / Chart / Progress Notes | Diabetes Mellitus - SOAP Note - 2 | SUBJECTIVE:, I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in ... | soap / chart / progress notes, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses, |
1,415 | Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983. | SOAP / Chart / Progress Notes | Dietary Consult - Diabetes - 2 | SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at ... | soap / chart / progress notes, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes, |
1,416 | Elevated PSA with nocturia and occasional daytime frequency. | SOAP / Chart / Progress Notes | Elevated PSA - Chart Note | REASON FOR VISIT: ,Elevated PSA with nocturia and occasional daytime frequency.,HISTORY: , A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues. The patient has had history of an elevated PSA and PSA in 2004 was 5.5. In 2003, he had undergone a biopsy by Dr. ... | soap / chart / progress notes, daytime frequency, psa, irritative symptoms, elevated psa, frequency, nocturia |
1,417 | Followup diabetes mellitus, type 1. | SOAP / Chart / Progress Notes | Diabetes Mellitus - SOAP Note - 1 | CHIEF COMPLAINT: ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:, Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar du... | soap / chart / progress notes, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars |
1,418 | Hand dermatitis. | SOAP / Chart / Progress Notes | Dermatitis - SOAP | SUBJECTIVE:, This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and ... | soap / chart / progress notes, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis |
1,419 | An 83-year-old diabetic female presents today stating that she would like diabetic foot care. | SOAP / Chart / Progress Notes | Diabetic Foot Care | S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth se... | soap / chart / progress notes, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic, |
1,420 | The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis. | SOAP / Chart / Progress Notes | Deviated Septum Repair - Followup | CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation. The patient has been using saline nasal wash 2-3 times daily, however, she states that she... | soap / chart / progress notes, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation |
1,421 | Elevated cholesterol and is on medication to lower it. | SOAP / Chart / Progress Notes | 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... | soap / chart / progress notes, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol |
1,422 | Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin. | SOAP / Chart / Progress Notes | Diabetes Mellitus Followup | PROBLEM LIST:,1. Type 1 diabetes mellitus, insulin pump.,2. Hypertension.,3. Hyperlipidemia.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus. Her last visit was approximately 4 months ago. Since that time, the patient states her health ha... | soap / chart / progress notes, endocrine clinic, insulin pump, diabetes mellitus, insulin, glycemic, fasting, polyuria, polydipsia, polyphagia, diabetes, |
1,423 | Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. | SOAP / Chart / Progress Notes | COPD & Pneumonia - SOAP | SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, she does not use oxygen at her independent assisted... | soap / chart / progress notes, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd |
1,424 | The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. | SOAP / Chart / Progress Notes | CyberKnife Treatment - Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatm... | soap / chart / progress notes, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife, |
1,425 | 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. | SOAP / Chart / Progress Notes | 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... | soap / chart / progress notes, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma, |
1,426 | Still having diarrhea, decreased appetite. | SOAP / Chart / Progress Notes | Clostridium Difficile Colitis Followup | SUBJECTIVE: ,The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile.,PHYSICAL EXAMINATION,GENERAL: Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS: Blood pressure 102/64, heart rate of 89, respira... | soap / chart / progress notes, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis, |
1,427 | D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6. Grade 1+ rectocele. | SOAP / Chart / Progress Notes | D&C & Hysteroscopy Followup | PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spot... | soap / chart / progress notes, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus |
1,428 | Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications. | SOAP / Chart / Progress Notes | Circumcision Followup | REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital. The patient had a pretty significant phimosis and his operative course was smooth. He did have a little bit of bleeding when he woke in recovery room, which re... | soap / chart / progress notes, circumcision, adhesions, followup circumcision, sutures, phimosis, |
1,429 | Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia. | SOAP / Chart / Progress Notes | Chronic Kidney Disease Followup | HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease. His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him. I have been trying to get him educated abou... | soap / chart / progress notes, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney |
1,430 | Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc. | SOAP / Chart / Progress Notes | Chiropractic Progress Note | CHIEF COMPLAINT: ,Hip pain.,HISTORY OF PRESENTING ILLNESS: ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Manage... | null |
1,431 | Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis. | SOAP / Chart / Progress Notes | Chronic Medical Conditions - Followup | REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:, The patient has been doing quite well since he was last seen. He comes in today with his daughter. He has had no symptoms of CAD or CHF. He had followup with Dr. X and she thought he was doing quite we... | soap / chart / progress notes, congestive heart failure, diabetes, hyperlipidemia, chronic renal insufficiency, arthritis, chronic medical conditions, heart, |
1,432 | Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia. | SOAP / Chart / Progress Notes | Chronic Kidney Disease Followup - 1 | PROBLEMS LIST:,1. Type 1 diabetes mellitus, insulin pump requiring.,2. Chronic kidney disease, stage III.,3. Sweet syndrome.,4. Hypertension.,5. Dyslipidemia.,6. Osteoporosis.,7. Anemia.,8. A 25-hydroxy-vitamin D deficiency.,9. Peripheral neuropathy manifested by insensate feet.,10. Hypothyroidism.,11. Diabe... | null |
1,433 | Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate. | SOAP / Chart / Progress Notes | Cervicalgia | FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both wi... | soap / chart / progress notes, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing, |
1,434 | A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina. | SOAP / Chart / Progress Notes | Chest Pain & Respiratory Insufficiency | We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have ni... | soap / chart / progress notes, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic |
1,435 | Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects. | SOAP / Chart / Progress Notes | Cervical Spinal Stenosis | REASON FOR VISIT: ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on... | null |
1,436 | Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks. | SOAP / Chart / Progress Notes | Cataract Extraction Followup | Her past medical history includes insulin requiring diabetes mellitus for the past 28 years. She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease. She is scheduled to see a gastroenterologist in the near future. She is taking Econopred 8 times a day to the right eye and... | soap / chart / progress notes, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, cornealNOTE,: 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 report... |
1,437 | 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. | SOAP / Chart / Progress Notes | 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 ... | soap / chart / progress notes, 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 accurac... |
1,438 | A 60-year-old female presents today for care of painful calluses and benign lesions. | SOAP / Chart / Progress Notes | Bunions and Calluses | S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint. She states that they do not hurt. No pain appears to be produced by active or passive range of motion or palpation and direct pressur... | soap / chart / progress notes, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar, |
1,439 | Problem of essential hypertension. Symptoms that suggested intracranial pathology. | SOAP / Chart / Progress Notes | Cardiology Progress Note | SUBJECTIVE:, The patient is a 78-year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She de... | soap / chart / progress notes, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial, |
1,440 | He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema. | SOAP / Chart / Progress Notes | CAD - 6-Month Followup | REASON FOR VISIT:, Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee. He is also having trouble getting his nerves under control. He is having stomach pains and occasi... | |
1,441 | Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction. | SOAP / Chart / Progress Notes | Cardiology Progress Note - 1 | SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.,CHEST: There is prolonged expiration.,CARDIOVASCULAR: First and second heart sounds are ... | soap / chart / progress notes, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep, |
1,442 | Dietary consultation for carbohydrate counting for type I diabetes. | SOAP / Chart / Progress Notes | Carbohydrate Counting | SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood ... | soap / chart / progress notes, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin |
1,443 | The patient seeks evaluation for a second opinion concerning cataract extraction. | SOAP / Chart / Progress Notes | Cataract - Second Opinion | SUBJECTIVE: ,The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has... | soap / chart / progress notes, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract, |
1,444 | Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA. | SOAP / Chart / Progress Notes | Breast Radiation Therapy Followup | DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiaz... | soap / chart / progress notes, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast, |
1,445 | Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia. | SOAP / Chart / Progress Notes | Atrial Fibrillation - SOAP | SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracin... | soap / chart / progress notes, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic, |
1,446 | A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. | SOAP / Chart / Progress Notes | Breast Cancer Followup | CHIEF COMPLAINT:,1. Metastatic breast cancer.,2. Enrolled is clinical trial C40502.,3. Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She ... | soap / chart / progress notes, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer, |
1,447 | School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder. | SOAP / Chart / Progress Notes | Asperger Disorder | SUBJECTIVE: ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. He appears confused and depressed at times. Mother also indicates that preservative questioning had come down, but he started... | soap / chart / progress notes, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger, |
1,448 | Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. | SOAP / Chart / Progress Notes | Breast Cancer Followup - 1 | CHIEF COMPLAINT:, Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS: ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right bre... | null |
1,449 | A 75-year-old female comes in with concerns of having a stroke. | SOAP / Chart / Progress Notes | Bell's Palsy | SUBJECTIVE:, The patient is a 75-year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently had something about three weeks ago whe... | soap / chart / progress notes, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s |
1,450 | A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate. | SOAP / Chart / Progress Notes | Atrial Flutter - Progress Note | HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day. This afternoon, when I am seeing the patient, nursing ... | soap / chart / progress notes, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter, |
1,451 | Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone. | SOAP / Chart / Progress Notes | Aplastic Anemia Followup | CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospita... | null |
1,452 | Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus. | SOAP / Chart / Progress Notes | Acquired Hypothyroidism Followup | PROBLEM LIST:,1. Acquired hypothyroidism.,2. Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3. Diabetes mellitus.,4. Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 yea... | soap / chart / progress notes, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism, |
1,453 | Acne with folliculitis. | SOAP / Chart / Progress Notes | Acne - SOAP | SUBJECTIVE:, The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flarin... | soap / chart / progress notes, acne with folliculitis, tazorac cream, acne, dermatology, tazorac, cream, folliculitis, |
1,454 | EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. | Sleep Medicine | Video EEG - 2 | IMPRESSION: ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. | sleep medicine, ekg artifact, video monitoring, wakefulness, drowsiness, eegNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcriptio... |
1,455 | A 23-year-old white female presents with complaint of allergies. | SOAP / Chart / Progress Notes | Allergic Rhinitis | SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. Sh... | soap / chart / progress notes, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic, |
1,456 | Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. | SOAP / Chart / Progress Notes | Anemia & Leukemia Followup | CHIEF COMPLAINT:,1. Chronic lymphocytic leukemia (CLL).,2. Autoimmune hemolytic anemia.,3. Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnos... | soap / chart / progress notes, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune, |
1,457 | EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region. | Sleep Medicine | Video EEG - 3 | PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally. The EEG background is symmetric. Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predomina... | sleep medicine, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription s... |
1,458 | The patient has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events. | Sleep Medicine | Video EEG - 1 | DATE OF EXAMINATION: , Start: 12/29/2008 at 1859 hours. End: 12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:, 12 hours, 29 minutes.,PATIENT HISTORY:, This is a 46-year-old female with a history of events concerning for seizures. The patient has a history of epilepsy and has also had non-epileptic events in the pa... | sleep medicine, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic, |
1,459 | This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology. | Sleep Medicine | Video EEG | TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1. AWAKE: Normal.,2. SLEEP: No acti... | sleep medicine, electroencephalography, eeg monitoring, video eeg, seizures, eeg, |
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 ... |
1,461 | Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial. | Sleep Medicine | Sleep Study Followup | REASON FOR VISIT:, This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to ... | null |
1,462 | The patient underwent an overnight polysomnogram. | Sleep Medicine | Overnight Polysomnogram | The patient underwent an overnight polysomnogram on 09/22/06 and the details of the polysomnographic study are reported separately. The highlights of the study include the following:,A. Obstructive apneas and hypopneas were identified with an overall apnea-hypopnea index of 15.2 events per hour in the supine position... | sleep medicine, periodic limb movement, cpap, limb movements in sleep, obstructive sleep apnea, overnight polysomnogram, sleep, overnight, polysomnogram, obstructive, apneas, |
1,463 | Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study. | Sleep Medicine | Pulmonary Consultation - 1 | CHIEF COMPLAINT:, Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the ... | null |
1,464 | Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. | Sleep Medicine | Sleep Apnea | REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to ... | sleep medicine, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, |
1,465 | Sleep study - patient with symptoms of obstructive sleep apnea with snoring. | Sleep Medicine | Sleep Study Interpretation | PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the pat... | sleep medicine, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index, |
1,466 | Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study. | Sleep Medicine | Obesity Hypoventilation Syndrome | HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. ... | sleep medicine, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity, |
1,467 | Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry. | Sleep Medicine | Sleep Difficulties | CLINICAL HISTORY: , This is a 16-year-old man evaluated for sleep difficulties. He states he is "feeling bad in the mornings" that he has daytime somnolence and "whenever I wake up I experience dizziness, weakness, stomachache, loss of appetite, drowsiness, overall sore body and a general feeling of unwell." He does ... | sleep medicine, sleep, sleep difficulties, mouth breather, epworth sleeping scale, stanford sleepiness scale, sleep onset latency, arousals, electroencephalogram, electromyogram, electrooculogram, electrocardiogram, polysomnogram, sleep apnea, periodic limb movement, hypopneas, accutane, |
1,468 | The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings. | Sleep Medicine | Polysomnography | PROCEDURE:, The test was performed in an observed hospital laboratory. The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.,The patient's ... | sleep medicine, thoracoabdominal impedance, oral/nasal thermistors, obstructive sleep apnea, titration study, eeg, eog, emgs, cpap, sleep, |
1,469 | Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. | Sleep Medicine | Electroencephalogram - 3 | IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested. | sleep medicine, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: 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 transcribe... |
1,470 | Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. | Sleep Medicine | Electroencephalogram - 2 | REPORT: ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE: ,This is a 51-year-old male, who is being evaluated for dizziness. Spontan... | sleep medicine, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram |
1,471 | Electroencephalographic findings and interpretation | Sleep Medicine | Electroencephalography | HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurri... | sleep medicine, electroencephalography, eeg, hz rhythm, parkinson's tremor, photic stimulation, frontal head region, temporal head region, muscle contractions, seizures, parkinson's, temporal, |
1,472 | Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal. | Sleep Medicine | Electroencephalogram - 1 | REPORT:, The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally. Little activity in the beta range is noted. Waves of 4-7 cycle/second of low amplitude were occasionally noted. Abundant movements and technical artifacts are noted throughout this tracing. Hyperventilation was not ... | sleep medicine, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical tr... |
1,473 | A 21-channel digital electroencephalogram was performed on a patient in the awake state. | Sleep Medicine | Electroencephalogram - 4 | PROCEDURE:, A 21-channel digital electroencephalogram was performed on a patient in the awake state. Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity. Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are... | sleep medicine, alpha activity, wave activity, hyperventilation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical tra... |
1,474 | The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. | Sleep Medicine | CPAP Titration Study | PROCEDURE: , The test was performed in an observed hospital laboratory due to the evidence of obstructive sleep apnea. The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.,CPAP TITRATION STUDY:, Total sleep time 425 minutes, sleep onset 7.8 mi... | sleep medicine, obstructive sleep apnea, cpap titration study, cpap titration, oral/nasal thermistors, thermistors ekg, oxygen saturation, eeg, eog, emg, thoracoabdominal, thermistors, ekg, oximetry, apnea, cpap, oral/nasalNOTE |
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, |
1,476 | Normal awake and drowsy (stage I sleep) EEG for patient's age. | Sleep Medicine | Electroencephalogram | DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. Du... | sleep medicine, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity |
1,477 | Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine. | Rheumatology | Rheumatology Progress Note | SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. S... | rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected, |
1,478 | Patient presents for treatment of suspected rheumatoid arthritis. | Rheumatology | Rheumatoid Arthritis - H&P | CHIEF COMPLAINT:, This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has exi... | null |
1,479 | A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. | Rheumatology | Pediatric Rheumatology Consult | HISTORY: ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic. He was sent here with a chief complaint of joint pain in several joints for few months. This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he s... | rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, |
1,480 | A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She is not on DMARD, but as she recently had a surgery followed by a probable infection. | Rheumatology | Rheumatoid Arthritis - Consult | HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She was followed by another rheumatologist. She says she has been off and on, on prednisone and Arava. The rheumatologist, as per the patient, would not want her to ... | rheumatology, prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains, |
1,481 | Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. | Rheumatology | Hand Discomfort - Followup | REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater ... | null |
1,482 | A 12-year-old with discoid lupus on the control with optimal regimen. | Rheumatology | Discoid Lupus | HISTORY: ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit. She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus. A has been doing well with just Plaquenil alone and m... | rheumatology, lupus, systemic lupus, acanthosis nigricans, discoid lupus, extremities, rash, erythema, discoid, |
1,483 | Consultation - an 87-year-old white female with weakness and a history of polymyositis. | Rheumatology | Consult - Weankness & Polymyositis | REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnor... | null |
1,484 | A lady with symptoms consistent with possible oligoarticular arthritis of her knees. | Rheumatology | Oligoarticular Arthritis - 2 | HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She sta... | rheumatology, arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular, |
1,485 | Ultrasound examination of the scrotum due to scrotal pain. Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. | Radiology | Ultrasound Scrotum | EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS: ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. The left testicle measures 5.1 x 2.8 x 3.0 cm. There is no evidence of intratesticular masses. There is normal ... | radiology, scrotal pain, epididymis, torsion, ultrasound examination, intratesticular masses, ultrasound, scrotal, testicles, scrotum, |
1,486 | X-RAY of the soft tissues of the neck. | Radiology | X-RAY - Neck Soft Tissues | EXAM: , Two views of the soft tissues of the neck.,HISTORY:, Patient has swelling of the left side of his neck.,TECHNIQUE:, Frontal and lateral views of the soft tissues of the neck were evaluated. There were no soft tissues of the neck radiographs for comparison. However, there was an ultrasound of the neck performe... | radiology, swelling, soft tissues, ultrasound, tonsils, adenoids, osseous structures, epiglottis, aryepiglottic folds, frontal and lateral, normal caliber, frontal, asymmetry, |
1,487 | A 17-year-old male with oligoarticular arthritis of his right knee. | Rheumatology | Oligoarticular Arthritis - 1 | HISTORY:, A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic. A is a 17-year-old male with oligoarticular arthritis of his right knee. He had a joint injection back in 03/2007 and since then he has been doing relatively well. He is taking Indocin only as needed even... | rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling, |
1,488 | This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade. | Radiology | Ultrasound OB - 5 | GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which... | null |
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, |
1,490 | A 27-year-old female with a size and date discrepancy. | Radiology | Ultrasound OB - 7 | GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM. Fetal Lie: Longitudinal. Fetal Presentation: Cephalic. Placenta: Anterior Grade I. Uterus: Normal. Cervix: Closed. Adnexa: Not seen. Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 3... | null |
1,491 | Pregnant female with nausea, vomiting, and diarrhea. OB ultrasound less than 14 weeks, transvaginal. | Radiology | Ultrasound OB - 8 | REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign. A yolk sac is visualized. What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0... | radiology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine |
1,492 | Ultrasound - a 22-year-old pregnant female. | Radiology | Ultrasound OB - 6 | GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix: | radiology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal, |
1,493 | Twin pregnancy with threatened preterm labor. | Radiology | Ultrasound OB - 4 | GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm con... | null |
1,494 | A 37 year-old female with twin pregnancy with threatened premature labor. | Radiology | Ultrasound OB - 3 | GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm co... | null |
1,495 | A 34-year old female with no fetal heart motion noted on office scan. | Radiology | Ultrasound OB - 2 | FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the end... | radiology, fetal heart motion, gestational sac, endometrial cavity, fetal pole, fetal heart, heart motion, gestational, fetal |
1,496 | Ultrasound of pelvis - menorrhagia. | Radiology | Ultrasound - Pelvis | EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm. It appears to be completely replaced by multiple ill-defined fibroids. The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids. The right ovary me... | radiology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis |
1,497 | Transvaginal ultrasound to evaluate pelvic pain. | Radiology | Ultrasound - Transvaginal | EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm. There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right. Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of u... | radiology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion, |
1,498 | OB Ultrasound - A 29-year-old female requests for size and date of pregnancy. | Radiology | Ultrasound OB - 1 | EXAM: , OB Ultrasound.,HISTORY:, A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There i... | radiology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cor... |
1,499 | Bilateral lower extremity ultrasound for deep venous thrombus. | Radiology | Ultrasound - Lower Extremity | EXAM: , Bilateral lower extremity ultrasound for deep venous thrombus.,REASON FOR EXAM: , Lower extremity edema bilaterally.,TECHNIQUE: , Colored, grayscale, and Doppler imaging is all employed.,FINDINGS: , This examination is limited. There is prominent edema bilaterally and there is large body habitus. These two li... | radiology, edema, grayscale images, deep venous thrombus, lower extremity, grayscale, doppler, ultrasound, extremity, |
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