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1,800 | Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke. | Psychiatry / Psychology | Neuropsychological Evaluation | REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehen... | null |
1,801 | This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. | Psychiatry / Psychology | Huntington's Disease - Consult | CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 3... | null |
1,802 | Bender-Gestalt Neurological Battery and Beck testing. | Psychiatry / Psychology | Neurobehavioral Assessment | BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation: 18,SUMMARY:, The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately neg... | psychiatry / psychology, bender-gestalt neurological battery, beck anxiety inventory, beck depression inventory, beck hopelessness scale, beck scale, suicide ideation, bender-gestalt test, beck testing, bender gestalt, beck, |
1,803 | Sample for Neuropsychological Evaluation | Psychiatry / Psychology | Neuropsychological Evaluation - 1 | REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having th... | psychiatry / psychology, neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis, |
1,804 | Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home. | Psychiatry / Psychology | Falls - Discharge Summary | CHIEF COMPLAINT:, Falls at home.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They... | null |
1,805 | The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. | Psychiatry / Psychology | Conversion Disorder | REASON FOR REFERRAL: ,The patient was referred to me by Dr. X of Children's Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder. I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time. After h... | psychiatry / psychology, developmental history, academic background, global assessment of functioning, normal school environment, conversion reactions, conversion disorder, conversion, background, environment, peers, disorder, axis, |
1,806 | Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability | Psychiatry / Psychology | Mental Status Evaluation | COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:, The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability. He is a 43-year-old married, white male who came unaccompanied to the evaluation. He... | null |
1,807 | The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression. | Psychiatry / Psychology | Bipolar Affective Disorder - Consult | IDENTIFYING DATA: ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT: ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the... | null |
1,808 | The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. | Psychiatry / Psychology | Attempted Suicide - Consult | IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says... | null |
1,809 | Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot. | Podiatry | Tarsectomy | PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy,... | podiatry, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone |
1,810 | Itchy red rash on feet - Tinea Pedis | Podiatry | Tinea Pedis - H&P | CHIEF COMPLAINT (1/1): ,This 24 year-old female presents today complaining of itchy, red rash on feet. Associated signs and symptoms: Associated signs and symptoms include tingling, right. Context: Patient denies any previous history, related trauma or previous treatments for this condition. Duration: Condition ... | null |
1,811 | Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. | Podiatry | Three Views - Foot | EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no r... | podiatry, three views, radiopaque, fractures, foot trauma |
1,812 | 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. | Psychiatry / Psychology | 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... | psychiatry / psychology, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger, |
1,813 | Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx. | Podiatry | Symes Amputation - Hallux | PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputa... | podiatry, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux |
1,814 | The patient was referred due to concerns regarding behavioral acting out as well as encopresis. | Psychiatry / Psychology | Adjustment Disorder & Encopresis | REASON FOR REFERRAL:, The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis. This is a 90-minute initial intake completed on 10/03/2007. I met with the patient's mother individually for the entire session. I reviewed with her the treatment, conse... | psychiatry / psychology, developmental background, axis, dsm iv, adjustment disorder, behavioral, adjustment, depression, oppositionality, encopresis, |
1,815 | Pain. Three views of the right ankle. Three views of the right ankle are obtained. | Podiatry | Three Views - Ankle | EXAM: , Three views of the right ankle.,INDICATIONS: ,Pain.,FINDINGS: , Three views of the right ankle are obtained. There is no evidence of fractures or dislocations. No significant degenerative changes or destructive osseous lesions of the ankle are noted. There is a small plantar calcaneal spur. There is no sig... | podiatry, three views, calcaneal, plantar, spur, osseous, ankle |
1,816 | Right foot series after a foot injury. | Podiatry | Right Foot Series | EXAM: , Right foot series.,REASON FOR EXAM: ,Injury.,FINDINGS: , Three images of the right foot were obtained. On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal. Also on a single image, there is a lucency seen ... | podiatry, sclerosis, calcaneus, metatarsal, foot series |
1,817 | Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. | Podiatry | Podiatry - Progress Note | SUBJECTIVE:, Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is curren... | podiatry, progress note, plantar fascitis, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel |
1,818 | Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility. | Psychiatry / Psychology | Agitation - ER Visit | HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated... | psychiatry / psychology, acute episode of agitation, agitation, |
1,819 | A 44-year-old, 250-pound male presents with extreme pain in his left heel. | Podiatry | Plantar Fasciitis | S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He als... | podiatry, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar, |
1,820 | Plantar fascitis, left foot. Partial plantar fasciotomy. | Podiatry | Plantar Fasciotomy | PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chi... | podiatry, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia |
1,821 | Toenails are discolored, thickened, and painful - Onychomycosis | Podiatry | Onychomycosis - H&P | CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,... | null |
1,822 | Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot. | Podiatry | Neuroma Excision | PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:, Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225... | podiatry, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia, |
1,823 | Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux. | Podiatry | Phalanx Amputation | PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/20... | podiatry, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal |
1,824 | Onychomycosis present, #1, #2, #3, #4, and #5 right and left. | Podiatry | Onychomycosis - 1 | S: , The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails. The patient has last seen primary in December 2006.,PRIMARY MEDICAL HISTORY: , Edema, venous insufficiency, schizophrenia, and anemia.,ALLERGIES: , THE PA... | podiatry, debrided, thickness, mycotic nails, onychomycosis, nails, |
1,825 | A 49-year-old female with ankle pain times one month, without a specific injury. | Podiatry | MRI Foot - 3 | EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course ... | podiatry, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon... |
1,826 | Pain and swelling in the right foot. | Podiatry | MRI Foot - 2 | EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active mar... | null |
1,827 | Patient with right ankle pain. | Podiatry | MRI Ankle - 1 | EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28... | null |
1,828 | Onychomycosis present, #1 right and #1 left. | Podiatry | Onychomycosis - 2 | S:, The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:, Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The p... | podiatry, length and thickness, mycotic nails, classic findings, onychomycosis, nails, |
1,829 | Pain and swelling in the right foot, peroneal tendon tear. | Podiatry | MRI Foot - 1 | EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:, Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effus... | podiatry, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid, |
1,830 | Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix. | Podiatry | Ingrown Toenail Removal | PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the ... | podiatry, toenail, nail matrix, ingrown toenail, painful, ingrown, |
1,831 | Excision of soft tissue mass, right foot. The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. | Podiatry | Mass Excision - Foot | PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY: ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. The patient has had pre... | podiatry, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle, |
1,832 | This patient has reoccurring ingrown infected toenails. | Podiatry | Infected Toenails | S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing ... | podiatry, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected, |
1,833 | Procedure note on Keller Bunionectomy | Podiatry | Keller Bunionectomy | PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female wa... | podiatry, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy, |
1,834 | MRI right ankle. | Podiatry | MRI Ankle - 2 | EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding t... | podiatry, ankle joint, bone, mri, ankle |
1,835 | Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation. | Podiatry | McBride Bunionectomy & Wedge Osteotomy | PREOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1. Right McBride bunionectomy.,2. Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle ... | podiatry, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy |
1,836 | Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux. | Podiatry | Hallux Infected Bone Resection | PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after ... | podiatry, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal, |
1,837 | Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound. | Podiatry | I&D & Foreign Body Removal | PREOPERATIVE DIAGNOSIS:, Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1. Incision and drainage, right foot.,2. Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off h... | podiatry, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot |
1,838 | Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection. | Podiatry | Gangrene Surgery | PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT: ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infecti... | podiatry, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital, |
1,839 | Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads. | Podiatry | Foreign Body Removal - Foot - 1 | PREOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,PROCEDURE PERFORMED:,1. Irrigation debridement.,2. Removal of foreign body of right foot.,ANESTHESIA:, S... | podiatry, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent, |
1,840 | Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. | Podiatry | 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... | podiatry, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful |
1,841 | Abscess of the left foot, etiology unclear at this time. Possibility of foreign body. | Podiatry | Foot Infection Management | REASON FOR CONSULTATION: ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot. He noticed a small dark spot. He did not remember having had any injuries to that ... | podiatry, accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess, |
1,842 | Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a w... | Podiatry | Foreign Body Removal - Foot | PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.... | podiatry, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound, |
1,843 | The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails. | Podiatry | Dystrophic Nails | S: , The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:, Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, ... | podiatry, debrided, nails, dystrophic nails, dystrophic |
1,844 | Patient dropped a weight on the dorsal aspects of his feet. | Podiatry | Foot Pain | CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an h... | null |
1,845 | An 83-year-old diabetic female presents today stating that she would like diabetic foot care. | Podiatry | 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... | podiatry, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic, |
1,846 | A 60-year-old female presents today for care of painful calluses and benign lesions. | Podiatry | 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... | podiatry, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar, |
1,847 | Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia. | Podiatry | Debridement - Foot Ulcer | PREOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1. Left lateral fifth r... | podiatry, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot |
1,848 | Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot. | Podiatry | Bunionectomy & Akin Osteotomy | PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2. Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents... | podiatry, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot |
1,849 | Arthroplasty of the right second digit. Hammertoe deformity of the right second digit. | Podiatry | Arthroplasty - Hammertoe | PREOPERATIVE DIAGNOSIS:, Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful ... | podiatry, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon |
1,850 | Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation. | Podiatry | Bunionectomy & Osteotomy | PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin b... | podiatry, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal |
1,851 | Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. | Podiatry | Bunionectomy - Austin - Akin | PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformi... | podiatry, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy |
1,852 | A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot. | Podiatry | Athlete's Foot | ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot. It often first appears between the toes. It can be a one-time occurrence or it can be chronic. The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible. It is ... | podiatry, tinea pedis, infection, foot, athlete's foot, trichophyton, itchy, athlete's foot tinea pedis, fungal skin infection, fungal, athlete's, |
1,853 | Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes. | Podiatry | Bunionectomy & Flexor Tenotomy | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and in... | podiatry, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, bla... |
1,854 | Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head. | Podiatry | Bone Removal - Metatarsal Head | PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA: ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mi... | podiatry, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone |
1,855 | Acute foot or ankle sprain, possible small fracture. | Podiatry | Ankle pain | CHIEF COMPLAINT:, Ankle pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts t... | podiatry, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture, |
1,856 | Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe. | Podiatry | Bunionectomy & Metatarsal Osteotomy | PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 3... | podiatry, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy, |
1,857 | Incision and drainage, first metatarsal head, left foot with culture and sensitivity. | Podiatry | Abscess with Cellulitis - Discharge Summary | ADMITTING DIAGNOSIS:, Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:, Status post I&D, left foot.,PROCEDURES:, Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:, The patient presented to Dr. X's office on 06/14/07 complaining of a painful lef... | podiatry, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage, |
1,858 | Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size. | Podiatry | Arthroplasty | PREOPERATIVE DIAGNOSES:,1. Hammertoe deformity, left fifth digit.,2. Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1. Hammertoe deformity, left fifth toe.,2. Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1. Arthroplasty of the left fifth digit proximal inte... | podiatry, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion |
1,859 | Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis. | Physical Medicine - Rehab | Therapeutic Recreation Initial Evaluation | HISTORY:, Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job. At discharge, he will live with his spouse in a new job. The home is single level with no steps.,Prior to admission, his wife reports that ... | physical medicine - rehab, endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic, |
1,860 | Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. | Physical Medicine - Rehab | Physical Therapy - Brain Tumor Removal | DIAGNOSIS:, Status post brain tumor removal.,HISTORY:, The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical thera... | null |
1,861 | Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received... | Physical Medicine - Rehab | Physical Therapy - Ankle Sprain | DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that w... | null |
1,862 | The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient... | Physical Medicine - Rehab | Physical Therapy - Osteoarthritis | DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nurs... | null |
1,863 | The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. | Physical Medicine - Rehab | Physical Therapy - Low Back Pain | HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one... | null |
1,864 | Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention. | Physical Medicine - Rehab | Physical Therapy - Back Pain | DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painf... | null |
1,865 | Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. | Physical Medicine - Rehab | Physical Therapy - Synovitis | DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The... | null |
1,866 | Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. | Physical Medicine - Rehab | Physical Therapy - Outpatient Rehab | SUMMARY: ,The patient has attended physical therapy from 11/16/06 to 11/21/06. The patient has 3 call and cancels and 3 no shows. The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE: ,The patient states pain still significant, primarily 1s... | null |
1,867 | Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared. | Physical Medicine - Rehab | Hip Fracture - Rehab Consult | ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture ... | null |
1,868 | Encephalopathy related to normal-pressure hydrocephalus. | Physical Medicine - Rehab | Encephalopathy - Rehab Consult | ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:, Diminished function secondary to above.,HISTORY: ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was dia... | null |
1,869 | Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 9 | NERVE CONDUCTION TESTING AND EMG EVALUATION,1. Right median sensory response 3.0, amplitude 2.5, distance 100.,2. Right ulnar sensory response 2.1, amplitude 1, distance 90.,3. Left median sensory response 3.0, amplitude 1.2, distance 100.,4. Left median motor response distal 4.2, proximal 9, amplitude 2.2, distanc... | null |
1,870 | Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain. | Physical Medicine - Rehab | Occupational Therapy Discharge Summary | DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional... | physical medicine - rehab, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation, |
1,871 | Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 6 | HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and ... | physical medicine - rehab, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, media... |
1,872 | A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. Abnormal electrodiagnostic study. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 8 | REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,T... | physical medicine - rehab, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction |
1,873 | A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 3 | HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005. At that time, she did not notice any specific injury. Five days later, she started getting abnormal right low back pain. At this time, it ... | physical medicine - rehab, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle |
1,874 | EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 4 | NERVE CONDUCTION STUDIES:, Bilateral ulnar sensory responses are absent. Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude. The left radial sensory response is normal and robust. Left sural response is absent. Left median motor distal latency is prolonged ... | physical medicine - rehab, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency,... |
1,875 | The patient is status post C3-C4 anterior cervical discectomy and fusion. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 5 | She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome. She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine. She has full strength in upper and lower extremities. Normal straig... | physical medicine - rehab, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve, |
1,876 | A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 2 | HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. She was undergoing a spinal epidural injection about a month ago and had worsening of r... | physical medicine - rehab, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decomp... |
1,877 | 1-month-old for a healthy checkup - Well child check | Pediatrics - Neonatal | Well-Child Check - 7 | SUBJECTIVE:, This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.,PAST MEDI... | |
1,878 | Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck pain and left low back pain. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 7 | HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005. She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolve... | physical medicine - rehab, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction, |
1,879 | The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand. | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 1 | HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, chang... | physical medicine - rehab, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduct... |
1,880 | History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness. | Physical Medicine - Rehab | EMG/Nerve Conduction Study | HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. ... | physical medicine - rehab, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes |
1,881 | A 3-month well-child check. | Pediatrics - Neonatal | Well-Child Check - 6 | SUBJECTIVE:, Patient presents with Mom and Dad for her 5-year 3-month well-child check. Family has not concerns stating patient has been doing well overall since last visit. Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack ... | pediatrics - neonatal, denver ii, child check, mom, diet, growth, denver, family, development, child, check, |
1,882 | 1-year well child check. | Pediatrics - Neonatal | Well-Child Check - 4 | SUBJECTIVE:, The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. Normal voiding... | pediatrics - neonatal, well child check, denver ii, child check, checkup, check, child, |
1,883 | A well-child check with concern of some spitting up quite a bit. | Pediatrics - Neonatal | Well-Child Check - 5 | SUBJECTIVE:, The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit. Mom wants to make sure that this is normal. The patient is nursing well every two to three hours. She does have some spitting up on occasion. It has happened two or three ... | pediatrics - neonatal, well-child check, denver ii, child check, growth, development, denver, cardiovascular, maternal, mother, spitting, father, child, check, asthma, family, mom, |
1,884 | A 9-month well-child check. | Pediatrics - Neonatal | Well-Child Check - 2 | SUBJECTIVE:, This 9-month-old Hispanic male comes in today for a 9-month well-child check. They are visiting from Texas until the end of April 2004. Mom says he has been doing well since last seen. He is up-to-date on his immunizations per her report. She notes that he has developed some bumps on his chest that ha... | pediatrics - neonatal, well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child, |
1,885 | Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. | Pediatrics - Neonatal | Tympanostomy & Myringotomy Tube Placement | PREOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA: ,Total IV gener... | pediatrics - neonatal, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy |
1,886 | Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. | Pediatrics - Neonatal | URI & Eustachian Congestion | HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting o... | pediatrics - neonatal, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar |
1,887 | Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis. | Pediatrics - Neonatal | Thyroid Mass Consult | REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS: ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now b... | null |
1,888 | A two week well-child check. | Pediatrics - Neonatal | Well-Child Check - 3 | SUBJECTIVE:, Patient presents with Mom for first visit to the office for two week well-child check. Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital. Nursing every two to three hours with normal voiding and stooling pattern. She does have a little bit of some ga... | null |
1,889 | Well child - Left lacrimal duct stenosis | Pediatrics - Neonatal | Well-Child Check - 1 | CHIEF COMPLAINT:, Well-child check.,HISTORY OF PRESENT ILLNESS:, This is a 12-month-old female here with her mother for a well-child check. Mother states she has been doing well. She is concerned about drainage from her left eye. Mother states she was diagnosed with a blocked tear duct on that side shortly after b... | pediatrics - neonatal, well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child, |
1,890 | The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis. | Pediatrics - Neonatal | Supraventricular Tachycardia - Consult | HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents; however, did note the patient to be quite dusky since the time of her birth; however, ... | pediatrics - neonatal, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary, |
1,891 | Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally. | Pediatrics - Neonatal | Sports Physical - 3 | SUBJECTIVE:, This is a 12-year-old male who comes in for healthy checkups and sports physical. No major concerns today. He is little bit congested at times. He has been told he is allergic to grasses. They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports. He has... | null |
1,892 | Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation. | Pediatrics - Neonatal | Single Frontal View - Chest - Pediatric | EXAM:, Single frontal view of the chest.,HISTORY:, Respiratory distress. The patient has a history of malrotation. The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:, Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:, ... | pediatrics - neonatal, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest |
1,893 | Sports physical with normal growth and development. | Pediatrics - Neonatal | Sports Physical - 1 | HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:, She takes meats, vegetables, and fruits. Eats well. Has may be 1 to 2 cups a day of milk. Her calcium intake could be better. She does not drink that much pop but she likes koolaid. Her stools are normal. Brushes her teeth. Sees a dentis... | |
1,894 | Consult and Spinal fluid evaluation in a 15-day-old | Pediatrics - Neonatal | Spinal fluid evaluation | HISTORY: ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly... | null |
1,895 | Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter. | Pediatrics - Neonatal | Septal Defect Repair | TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagn... | pediatrics - neonatal, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atr... |
1,896 | Pediatric Gastroenterology - Rectal Bleeding Consult. | Pediatrics - Neonatal | Rectal Bleeding - 1-year-old | HISTORY OF PRESENT ILLNESS:, This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was ha... | null |
1,897 | Frontal and lateral views of the hip and pelvis. | Pediatrics - Neonatal | Slipped Capital Femoral Epiphysis (SCFE) | EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of ... | pediatrics - neonatal, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip |
1,898 | This patient was seen in clinic for a school physical. | Pediatrics - Neonatal | School Physical - 1 | SUBJECTIVE:, This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:, She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited. She does not drink a whole lot of pop. Her stools are normal. Brushes her teeth, sees a dentist.,Developmental History: Hearing and visio... | pediatrics - neonatal, school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash, |
1,899 | Well-child check and school physical. | Pediatrics - Neonatal | School Physical - 2 | CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially ... | null |
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