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1,700 | HCT: Subdural hemorrhage. | Radiology | CT Brain: Subdural Hemorrhage. | CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of sp... | radiology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech, |
1,701 | CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi). | Radiology | CT Brain - Calcification of Basal Ganglia | CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >50... | radiology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain, |
1,702 | CT Brain: Suprasellar aneurysm, pre and post bleed. | Radiology | CT Brain - Aneurysm | CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, ... | radiology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain, |
1,703 | Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast. | Radiology | CT Abdomen & Pelvis - OB-GYN | EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDING... | radiology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen |
1,704 | Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained. | Radiology | CT Abdomen & Pelvis - 7 | REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lu... | radiology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast |
1,705 | Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300. | Radiology | CT Abdomen & Pelvis - 8 | CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:, Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100... | radiology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen |
1,706 | Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300. | Radiology | CT Angiography | CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE: ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: ,There is no evidence for pulmonary arterial embol... | radiology, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue, |
1,707 | CT abdomen without contrast and pelvis without contrast, reconstruction. | Radiology | CT Abdomen & Pelvis - 5 | EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is norma... | radiology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast, |
1,708 | Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300. | Radiology | CT Angiography - 1 | CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: ,Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence ... | radiology, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism, |
1,709 | Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. | Radiology | CT Abdomen & Pelvis - 6 | REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the... | radiology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct |
1,710 | CT brain (post craniectomy) - RMCA stroke and SBE. | Radiology | CT Brain | CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine culture... | radiology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness, |
1,711 | Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. | Radiology | CT Abdomen & Pelvis - 9 | CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:, Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, adrenal glands, and kidneys are u... | radiology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue, |
1,712 | Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast. | Radiology | CT Abdomen & Pelvis - 10 | CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable. Within the ... | radiology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen, |
1,713 | CT abdomen and pelvis without contrast, stone protocol, reconstruction. | Radiology | CT Abdomen & Pelvis - 4 | EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatatio... | radiology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast, |
1,714 | CT scan of the abdomen and pelvis without and with intravenous contrast. | Radiology | CT Abdomen & Pelvis - 2 | EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. O... | radiology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen, |
1,715 | Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast. | Radiology | CT Abdomen & Pelvis - 11 | EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen... | radiology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen, |
1,716 | CT of the abdomen and pelvis without contrast. | Radiology | CT Abdomen & Pelvis - 3 | EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:, Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the s... | radiology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen, |
1,717 | CT Abdomen and Pelvis with contrast | Radiology | CT Abdomen & Pelvis - 1 | EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bas... | radiology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct |
1,718 | A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator. | Radiology | Coronary CT Angiography (CCTA) - 5 | COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Exami... | null |
1,719 | CT Abdomen & Pelvis W&WO Contrast | Radiology | CT Abdomen & Pelvis | EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison i... | radiology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen, |
1,720 | CCTA with Cardiac Function/Calcium Scoring | Radiology | Coronary CT Angiography (CCTA) - 2 | CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG ... | radiology, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anteri... |
1,721 | Coronary Artery CTA with Calcium Scoring and Cardiac Function | Radiology | Coronary CT Angiography (CCTA) - 3 | EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did rece... | radiology, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography, |
1,722 | Conformal simulation with coplanar beams. This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. | Radiology | Conformal Simulation | CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing... | radiology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: 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 transcript... |
1,723 | A 51-year-old male with chest pain and history of coronary artery disease. | Radiology | Coronary CT Angiography (CCTA) - 4 | COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath ... | null |
1,724 | CCTA with cardiac function and calcium scoring. | Radiology | Coronary CT Angiography (CCTA) - 1 | HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agen... | radiology, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, ather... |
1,725 | Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion. | Radiology | Chest PA & Lateral | EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, dif... | radiology, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax, |
1,726 | Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms. | Radiology | Cerebral Angiogram & MRA | CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and... | radiology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram |
1,727 | Chest CT - Thymoma and history of ocular myasthenia gravis. | Radiology | Chest CT - Myasthenia Gravis | CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was ... | radiology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody, |
1,728 | Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery. | Radiology | Cerebral Angiogram - Left ICA/PCA Aneurysm | CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and... | radiology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram, |
1,729 | Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized. | Radiology | Chest Pulmonary Angio | EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The prox... | radiology, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio |
1,730 | Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection. | Radiology | Cerebral Angiogram - Lateral Medullary Syndrome | CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty wal... | radiology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral, |
1,731 | Concomitant chemoradiotherapy for curative intent patients. | Radiology | Concomitant Chemoradiotherapy | CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate a... | radiology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: 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 transcr... |
1,732 | Patient with chest pains, CAD, and cardiomyopathy. | Radiology | Cardiac Radionuclide Stress Test | INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:, Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart ra... | radiology, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear |
1,733 | Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery. | Radiology | Carotid & Cerebral Arteriograms | EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measu... | radiology, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire, |
1,734 | 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. | Radiology | 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 ... | radiology, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill, |
1,735 | Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx). | Radiology | Cerebral Angiogram | CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakeni... | null |
1,736 | Bilateral carotid ultrasound. | Radiology | Carotid Ultrasound | EXAM:, Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE: ,Color grayscale and Doppler analysis is employed.,FINDINGS:, On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only. At the level of the carotid bifurcation, there is heterogeneous ... | radiology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity |
1,737 | Carotid Ultrasonic & Color Flow Imaging | Radiology | Carotid Doppler Report | Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID ... | radiology, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery, |
1,738 | Bilateral Mammogram, (abnormal) additional views requested | Radiology | Bilateral Mammogram | EXAM:, Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study... | radiology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography, |
1,739 | Carotid artery angiograms. | Radiology | Bilateral Carotid Angiography | PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via rig... | radiology, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram, |
1,740 | Ultrasound BPP - Advanced maternal age and hypertension. | Radiology | Biophysical Profile - 1 | HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of de... | radiology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal, |
1,741 | Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast. | Radiology | Breast Ultrasound & Biopsy | EXAM: ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patien... | radiology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound, |
1,742 | BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes. | Radiology | Biophysical Profile | CLINICAL HISTORY:, Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation. The placenta was posterior in position. There was normal fetal breathing movement, gross body ... | radiology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE |
1,743 | Brain CT and MRI - suprasellar mass (pituitary adenoma) | Radiology | Brain MRI - Pituitary Adenoma | CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial h... | radiology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar, |
1,744 | Barium enema - history of encopresis and constipation. | Radiology | Barium Enema | EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic ... | radiology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium, |
1,745 | Arterial imaging of bilateral lower extremities. | Radiology | Arterial Imaging | INDICATIONS:, Peripheral vascular disease with claudication.,RIGHT:, ,1. Normal arterial imaging of right lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic.,4. Ankle brachial index is 0.96.,LEFT:,1. Normal arterial imaging of left lower extremity.,2. Peak systolic velocity ... | radiology, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial i... |
1,746 | MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement. | Radiology | Alzheimer Disease | CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due t... | radiology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pe... |
1,747 | Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery. | Radiology | Angiogram & StarClose Closure | EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,F... | radiology, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral, |
1,748 | CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain. | Radiology | Arachnoid Cyst | CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume a... | radiology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid |
1,749 | Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan. | Radiology | Adenosine Nuclear Scan | INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were n... | radiology, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear, |
1,750 | MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan). | Radiology | Acute Intracerebral Hemorrhage | CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other... | null |
1,751 | MRI - Arteriovenous malformation with hemorrhage. | Radiology | AVM with Hemorrhage | CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not a... | radiology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, neurology, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation, |
1,752 | MRI - Right temporal lobe astrocytoma. | Radiology | Astrocytoma | CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He... | radiology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal, |
1,753 | 2-D Echocardiogram | Radiology | 2-D Echocardiogram - 2 | 1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the ... | radiology, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery |
1,754 | 3-Dimensional Simulation. This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. | Radiology | 3-Dimensional Simulation | 3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side... | radiology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLin... |
1,755 | 2-D Echocardiogram | Radiology | 2-D Echocardiogram - 3 | 2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imagin... | radiology, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sa... |
1,756 | Echocardiogram and Doppler | Radiology | 2-D Echocardiogram - 4 | DESCRIPTION:,1. Normal cardiac chambers size.,2. Normal left ventricular size.,3. Normal LV systolic function. Ejection fraction estimated around 60%.,4. Aortic valve seen with good motion.,5. Mitral valve seen with good motion.,6. Tricuspid valve seen with good motion.,7. No pericardial effusion or intracardia... | radiology, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve |
1,757 | A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall. | Psychiatry / Psychology | Recheck of ADHD Meds | SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like... | psychiatry / psychology, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall, |
1,758 | 2-D M-Mode. Doppler. | Radiology | 2-D Echocardiogram - 1 | 2-D M-MODE: , ,1. Left atrial enlargement with left atrial diameter of 4.7 cm.,2. Normal size right and left ventricle.,3. Normal LV systolic function with left ventricular ejection fraction of 51%.,4. Normal LV diastolic function.,5. No pericardial effusion.,6. Normal morphology of aortic valve, mitral valve, tr... | radiology, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv |
1,759 | Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action. | Psychiatry / Psychology | Psychological Evaluation | COMPREHENSIVE CLINICAL PSYCHOLOGICAL EVALUATION,CURRENT MEDICATIONS:, Nexium 4 mg 4 times per day, Propanolol 10 mg 4 times a day, Spironolactone 100 mg 3 times per day, Lactulose 60 cc's 3 times a day.,GENERAL OBSERVATIONS: ,Mr. Abc, a 54-year-old black married male who was referred for a Comprehensive Clinical Psyc... | null |
1,760 | Psychosocial Evaluation of patient before kidney transplant. | Psychiatry / Psychology | 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 |
1,761 | Psychological Testing for ADHD | Psychiatry / Psychology | Psychological Testing | REFERRAL QUESTIONS:, Mr. Abcd was referred for psychological assessment by his primary medical provider, to help clarify his diagnosis, especially with respect to Attention Deficit Hyperactivity Disorder, a depression, or a Bipolar Spectrum Disorder. The information will be used for treatment planning.,BACKGROUND INF... | psychiatry / psychology, psychological testing, adhd, attention deficit hyperactivity disorder, bipolar spectrum disorder, cpt-ii, mmpi-2, posttraumatic stress disorder, welsh code, depression, psychological assessment, personality disorder, family stressors, posttraumatic stress, disorder, attention, psychological, |
1,762 | Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation. | Psychiatry / Psychology | Psychosocial Eval - Donor - 1 | PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A. DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are... | null |
1,763 | Psychosocial evaluation of kidney donor. Questions - Answers | Psychiatry / Psychology | Psychosocial Eval - Donor | DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how ... | null |
1,764 | Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures. | Radiology | 2-D Doppler | 2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic funct... | radiology, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation, |
1,765 | She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. | Psychiatry / Psychology | Psychiatric Consult - 2 | HISTORY OF PRESENT ILLNESS:, This is a 41-year-old registered nurse (R.N.). She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. She notes starting in January, her husband of five yea... | psychiatry / psychology, citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood |
1,766 | Discharge summary of a patient with depression and high risk behavior. | Psychiatry / Psychology | Psychiatric Discharge Summary - 2 | DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1. | null |
1,767 | Psychiatric evaluation for major depression without psychotic features. | Psychiatry / Psychology | Psychiatric Evaluation - 2 | IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:, Depression.,HISTORY OF PRESENT ILLNESS:, The patient's depression began in her teenage years. Sleep has been poor, for multiple reasons. She has obstructive sleep apnea, and has difficulties with a child who has insomnia r... | null |
1,768 | Admission Psychiatric Evaluation | Psychiatry / Psychology | Psychiatric Evaluation - 4 | ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA: ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in b... | null |
1,769 | Patient with a long history of depression and attention deficits. | Psychiatry / Psychology | Psychiatric Evaluation - 1 | IDENTIFYING DATA:, The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:, The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:, The patient has been receiving servi... | null |
1,770 | The patient was discharged by court as a voluntary drop by prosecution. | Psychiatry / Psychology | Psychiatric Discharge Summary | DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , Th... | psychiatry / psychology, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis, |
1,771 | Psychiatric evaluation for ADHD, combined type. | Psychiatry / Psychology | Psychiatric Evaluation - 3 | IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr. Circumstances leading to this admission: In the past, ABCD has been diagnosed and treated for ... | null |
1,772 | Discharge summary of a patient with mood swings and oppositional and defiant behavior. | Psychiatry / Psychology | Psychiatric Discharge Summary - 1 | DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1. | null |
1,773 | Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse. | Psychiatry / Psychology | Psychiatric Consult - 1 | HISTORY OF PRESENT ILLNESS:, This is a 53-year-old widowed woman, she lives at ABC Hotel. She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis. She has been refusing cardiac catheter and she may well need aortic valve replacement. She states that she does not want heart surgery ... | psychiatry / psychology, organic brain syndrom, substance abuse, bipolar disorder, mental, abuse, |
1,774 | Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome. | Psychiatry / Psychology | Psychiatric Assessment | IDENTIFICATION OF PATIENT: , This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian.,CHIEF COMPLAINT:, "I'm bipolar and I have severe anxiety disorder. I have posttraumatic stress syndrome." ,HISTORY OF PRESENT ILLNESS: , At age 19, Ms. Abc ... | null |
1,775 | Psychiatric consultation for substance abuse. | Psychiatry / Psychology | Psych Consult - Substance abuse | REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use. The patient says he had been sober from any illicit substance for 15 months prior to most rece... | null |
1,776 | Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior. | Psychiatry / Psychology | Psychiatric Consult | HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment,... | psychiatry / psychology, noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis, |
1,777 | A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. | Psychiatry / Psychology | Psych Consult - Paranoia | IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , "I am not sure." The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , T... | null |
1,778 | Psychiatric History and Physical - Patient with schizoaffective disorder. | Psychiatry / Psychology | Psych H&P - 2 | HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of "manic" symptoms due to recent medication adjustments. Th... | null |
1,779 | Psychiatric History and Physical - Patient with major depression | Psychiatry / Psychology | Psych H&P - 1 | HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother. The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and... | psychiatry / psychology, history of present illness:, global assessment of functioning, mental status examination, major depression, psychiatric, abuse, behavior, depression, mental health, mental health ward, psychiatric disability, sexually abused, substance abuse, health, |
1,780 | A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months. | Psychiatry / Psychology | Psych Consult - Schizophrenia | IDENTIFYING DATA:, The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The pat... | null |
1,781 | Patient with a history of PTSD, depression, and substance abuse. | Psychiatry / Psychology | Psych Consult - Psychosis | IDENTIFYING DATA:, Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son, but parents removed son from ... | psychiatry / psychology, ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis, |
1,782 | The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. | Psychiatry / Psychology | Psych Consult - Psychosis - 1 | IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of uri... | null |
1,783 | Psychiatric consultation for management of pain medications. | Psychiatry / Psychology | Psych Consult - Pain Meds | REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden ch... | null |
1,784 | Psychiatric Consultation of patient with altered mental status. | Psychiatry / Psychology | Psych Consult - Altered Mental Status | REASON FOR CONSULT:, Altered mental status.,HPI:, The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month. Last night, ... | null |
1,785 | Psychiatric consultation of patient with lethargy. | Psychiatry / Psychology | Psych Consult - Lethargy | REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:, The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depressi... | null |
1,786 | Psychiatric Consultation of patient with major depression disorder. | Psychiatry / Psychology | Psych Consult - Depression - 2 | REASON FOR CONSULT:, Depression.,HPI:, The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006. The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty. Soon after discharge, the patient was readm... | null |
1,787 | Psychiatric Consultation of patient with dementia. | Psychiatry / Psychology | Psych Consult - Dementia | REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen... | psychiatry / psychology, reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultati... |
1,788 | Psychiatric Consultation of patient with recurring depression. | Psychiatry / Psychology | Psych Consult - Depression - 1 | CC: , "Five years ago, I stopped drinking and since that time, I have had severe depression. I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again. I started lithium three weeks ago.",HPI: ,The patient is a 45-year-old married white female without children currently ... | null |
1,789 | A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability. | Psychiatry / Psychology | Psych Consult - Bipolar Affective Disorder | IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for tr... | null |
1,790 | Psychiatric consultation for alcohol withdrawal and dependance. | Psychiatry / Psychology | Psych Consult - Alcohol Withdrawal | REASON FOR CONSULT:, Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal. The patient had been on a drinking binge for t... | null |
1,791 | The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission. | Psychiatry / Psychology | Psych Consult - Assaultive Behavior | IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated... | null |
1,792 | The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. | Psychiatry / Psychology | Neuropsychological Evaluation - 4 | REASON FOR REFERRAL:, The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment th... | null |
1,793 | Psychiatric Consultation of patient with anxiety. | Psychiatry / Psychology | Psych Consult - Anxiety | REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:, "I felt anxious yesterday.",HPI:, A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.... | null |
1,794 | The patient was referred due to a recent admission for pseudoseizures. | Psychiatry / Psychology | Pseudoseizures | REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures. This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother. I have reviewed with her the boundaries of confidentiality and the treat... | psychiatry / psychology, conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures, |
1,795 | The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. | Psychiatry / Psychology | Neuropsychological Evaluation - 5 | PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercis... | psychiatry / psychology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, |
1,796 | Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decis... | Psychiatry / Psychology | Neuropsychological Evaluation - 3 | REASON FOR REFERRAL:, The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well.... | null |
1,797 | A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope. | Psychiatry / Psychology | Neuropsychological Evaluation - 2 | REASON FOR REFERRAL: ,The patient was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS... | null |
1,798 | Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved. | Psychiatry / Psychology | Mental Status Changes - Consult | CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had ... | psychiatry / psychology, alzheimer's, no loss consciousness, mental status, |
1,799 | Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. | Psychiatry / Psychology | Major Depressive Disorder - IME Consult | IDENTIFYING DATA: ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy le... | psychiatry / psychology, muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric, |
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