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1,900 | Well-child check sports physical - Well child asthma with good control, allergic rhinitis. | Pediatrics - Neonatal | Sports Physical - 2 | CHIEF COMPLAINT:, Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:, This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immun... | null |
1,901 | A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. | Pediatrics - Neonatal | Pediatric Rheumatology Consult | HISTORY: ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic. He was sent here with a chief complaint of joint pain in several joints for few months. This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he s... | pediatrics - neonatal, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, |
1,902 | Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem. | Pediatrics - Neonatal | Prematurity - Discharge Summary | ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS: ,This i... | null |
1,903 | A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever. | Pediatrics - Neonatal | Reactive Airway Disease | CHIEF COMPLAINT AND IDENTIFICATION:, A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and alb... | null |
1,904 | A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral. | Pediatrics - Neonatal | Otitis Media - H&P | CHIEF COMPLAINT:, This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotic... | null |
1,905 | 9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months. | Pediatrics - Neonatal | Pediatric - Letter | Sample Address,RE: Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing, cough and shortness of breath over... | pediatrics - neonatal, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma, |
1,906 | He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. | Pediatrics - Neonatal | Pediatric Urology Letter | XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE: XXXX, XXXX ,MR#: 0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic. I appreciate you speaking with me while he was in clinic. He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of ... | pediatrics - neonatal, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology, |
1,907 | Increasing oxygen requirement. Baby boy has significant pulmonary hypertension. | Pediatrics - Neonatal | Pulmonary Hypertension - Pediatric Consult | INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history o... | pediatrics - neonatal, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary |
1,908 | Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. | Pediatrics - Neonatal | Patent Ductus Arteriosus Ligation | TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-si... | pediatrics - neonatal, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation |
1,909 | Template for History and Physical for a newborn. | Pediatrics - Neonatal | Normal Newborn H&P Template | HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. T... | null |
1,910 | Fever, otitis media, and possible sepsis. | Pediatrics - Neonatal | Otitis Media - Discharge Summary | ADMITTING DIAGNOSES:,1. Fever.,2. Otitis media.,3. Possible sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal cong... | pediatrics - neonatal, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever |
1,911 | Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress. | Pediatrics - Neonatal | Normal Newborn Infant Physical Exam | GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterall... | pediatrics - neonatal, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant, |
1,912 | A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures. | Pediatrics - Neonatal | New Onset Seizure | REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febri... | null |
1,913 | The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. | Pediatrics - Neonatal | Neonatal Discharge Summary | HOSPITAL COURSE:, The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5:57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions, with pr... | pediatrics - neonatal, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge, |
1,914 | Normal child physical exam template. | Pediatrics - Neonatal | Normal Child Exam Template | CHILD PHYSICAL EXAMINATION,VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.,GENERAL APPEARANCE: Well.,BREATHING: Unlabored.,SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.,HEAD: Normal. Fontanelles are soft and flat. Su... | pediatrics - neonatal, child physical examination, physical, genitalia, child, |
1,915 | Skull, complete, five images. | Pediatrics - Neonatal | Multiple Images of Skull (Pediatric) | EXAM:, Skull, complete, five images,HISTORY:, Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated. There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure. There is n... | pediatrics - neonatal, craniosynostosis, plagiocephaly, complete five images, multiple images, radiographic, images, skull, |
1,916 | Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. | Pediatrics - Neonatal | Neonatal Discharge Summary - 1 | ADMITTING DIAGNOSES:, Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. Baby was born at ABCD Hospital at 1333 on 07/14/2006. Mother i... | pediatrics - neonatal, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant, |
1,917 | Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. | Pediatrics - Neonatal | Mastoiditis - Discharge Summary | DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blo... | |
1,918 | Mediastinal exploration and delayed primary chest closure. The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. | Pediatrics - Neonatal | Mediastinal Exploration | TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which ... | pediatrics - neonatal, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest |
1,919 | This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. | Pediatrics - Neonatal | Kawasaki Disease - Discharge Summary | ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated ne... | pediatrics - neonatal, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin |
1,920 | The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection. | Pediatrics - Neonatal | Neuroblastoma - Consult | REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and... | null |
1,921 | This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. | Pediatrics - Neonatal | Neonatal Consult | INFORMANT:, Dad on phone. Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY: ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being... | null |
1,922 | A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur. | Pediatrics - Neonatal | Infant Not Gaining Weight | CHIEF COMPLAINT:, Not gaining weight.,HISTORY OF PRESENT ILLNESS:, The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-t... | null |
1,923 | Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.
| Pediatrics - Neonatal | Inguinal Hernia & Hydrocele Repair | PREOPERATIVE DIAGNOSIS: ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE: ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on t... | pediatrics - neonatal, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis |
1,924 | A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. | Pediatrics - Neonatal | Infantile Spasms | CHIEF COMPLAINT:, Arm and leg jerking.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These mo... | null |
1,925 | 4-day-old with hyperbilirubinemia and heart murmur. | Pediatrics - Neonatal | Hyperbilirubinemia - 4-day-old | HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn a... | pediatrics - neonatal, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia, |
1,926 | Gastrostomy, a 6-week-old with feeding disorder and Down syndrome. | Pediatrics - Neonatal | Gastrostomy | PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to C... | pediatrics - neonatal, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy |
1,927 | Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access. | Pediatrics - Neonatal | Fundoplication & Gastrostomy Followup | REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feedin... | pediatrics - neonatal, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, |
1,928 | Head injury, anxiety, and hypertensive emergency. | Pediatrics - Neonatal | Head Injury | CHIEF COMPLAINT:, Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizz... | null |
1,929 | Pediatric Gastroenterology - History of gagging. | Pediatrics - Neonatal | Gagging - 3-year-old | HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rec... | pediatrics - neonatal, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube, |
1,930 | Questionable foreign body, right nose. Belly and back pain. Mild constipation. | Pediatrics - Neonatal | Foreign Body - Right Nose | CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels... | |
1,931 | Irritable baby, 6-week-old, with fever for approximately 24 hours. | Pediatrics - Neonatal | H&P - Infant with fever | CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room... | null |
1,932 | Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency. | Pediatrics - Neonatal | Goldenhar Syndrome - Discharge Summary | ADMITTING DIAGNOSES,1. Vomiting, probably secondary to gastroenteritis.,2. Goldenhar syndrome.,3. Severe gastroesophageal reflux.,4. Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1. Gastroenteritis versus bowel obstruction.,2. Gastroesophageal reflux.,3. Goldenhar syndrome.,4. Anemia,... | null |
1,933 | 13 years old complaining about severe ear pain - Chronic otitis media. | Pediatrics - Neonatal | Ear pain - Pediatric Consult | PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibioti... | null |
1,934 | Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure. | Pediatrics - Neonatal | Circumcision - Infant | PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. ... | pediatrics - neonatal, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant |
1,935 | The patient is 14 months old, comes in with a chief complaint of difficulty breathing. | Pediatrics - Neonatal | Difficulty Breathing - ER Visit | HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get wors... | null |
1,936 | A 3-year-old abrupt onset of cough and increased work of breathing. | Pediatrics - Neonatal | Discharge Summary - Respiratory Distress | ADMITTING DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,DISCHARGE DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,3. Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who ... | null |
1,937 | A 2-month-old female with 1-week history of congestion and fever x2 days. | Pediatrics - Neonatal | Congestion & Fever - 2-month-old | CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid b... | null |
1,938 | Congestion, tactile temperature. | Pediatrics - Neonatal | Congestion - 21-day-old | CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any p... | null |
1,939 | Newborn circumcision. The penile foreskin was removed using Gomco. | Pediatrics - Neonatal | Circumcision - Newborn | PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:, Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:, The baby was prepared and draped in a sterile manner. Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock. The penile fores... | pediatrics - neonatal, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile |
1,940 | Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents. | Pediatrics - Neonatal | Circumcision - Child | PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of t... | pediatrics - neonatal, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: 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 trans... |
1,941 | A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. | Pediatrics - Neonatal | Congestion & Cough - 5-month-Old | CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough w... | null |
1,942 | A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. | Pediatrics - Neonatal | Chronic Otitis Media | CHIEF COMPLAINT:, Chronic otitis media.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane pe... | pediatrics - neonatal, chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media, |
1,943 | Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter. | Pediatrics - Neonatal | Broviac Catheter Placement | PREOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,ANESTHESIA:, General.,PROCEDURE:, Placement of left subclavian 4-French Broviac catheter.,INDICATIONS: ,The patient is... | pediatrics - neonatal, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous, |
1,944 | Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. | Pediatrics - Neonatal | Chest Closure | PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected... | pediatrics - neonatal, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation |
1,945 | Health maintenance exam for 1-year-old female. | Pediatrics - Neonatal | 1-year-old Exam - H&P | CHIEF COMPLAINT:, This 1-year-old female presents today for a health maintenance exam. Patient was accompanied by mother.,The child eats 3 meals a day plus 2 snacks and is off the bottle. She sleeps through the night. She takes morning and afternoon naps. Mother is concerned about child's red, matted eye and not w... | null |
1,946 | 1+ year, black female for initial evaluation of a lifelong history of atopic eczema. | Pediatrics - Neonatal | Atopic Eczema | SUBJECTIVE:, This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working no... | pediatrics - neonatal, dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel, |
1,947 | Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph. | Pain Management | Tun-L Catheter Placement | PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,... | pain management, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle, |
1,948 | A 5-month-old boy brought by his parents because of 2 days of cough. | Pediatrics - Neonatal | A 5-month-old boy with cough | CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and h... | null |
1,949 | Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. | Pain Management | Trigger Point Injection | OPERATION:, | pain management, myofascial spasm, trigger point injection, trigger, injection, spasm |
1,950 | Mother states he has been wheezing and coughing. | Pediatrics - Neonatal | Asthma in a 5-year-old | CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asth... | null |
1,951 | Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine. | Pain Management | Transforaminal Epidural Steroid Injection - 1 | PROCEDURE: ,Transforaminal Epidural, lumbar.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infe... | pain management, epidural lumbar, facet joints, transforaminal epidural, injection, transforaminal, epidural, lumbar, fluoroscopy, needle, |
1,952 | Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm. | Pain Management | Tenosynovectomy & Cortisone Injection | PREOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A... | pain management, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone, |
1,953 | Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique. | Pain Management | Thoracic epidural steroid injection | PROCEDURE: , Thoracic epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal ma... | pain management, loss of resistance, cerebrospinal fluid, thoracic epidural steroid injection, fluoroscopy, thoracic, steroid, epidural, injection, |
1,954 | Flexible Bronchoscopy (pediatric) | Pediatrics - Neonatal | Bronchoscopy - Pediatric | FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of t... | pediatrics - neonatal, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are pro... |
1,955 | Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance. | Pain Management | Transforaminal Epidural Steroid Injection | PROCEDURE: , Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,PATIENT PROFILE: , This is a 44-year-old female. The patient reports greatly increasing pain over the past several weeks. In addition,... | null |
1,956 | Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter. | Pain Management | SynchroMed Pump Placement | PROCEDURES:,1. Placement of SynchroMed infusion pump.,2. Tunneling of SynchroMed infusion pump catheter,3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the pati... | pain management, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision, |
1,957 | Consultation for right shoulder pain. | Pain Management | Shoulder Pain Consult | CHIEF COMPLAINT:, Right shoulder pain.,HISTORY OF PRESENT PROBLEM: | pain management, shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder, |
1,958 | Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation. | Pain Management | Radiofrequency Thermocoagulation | PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with B... | pain management, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch |
1,959 | Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome. | Pain Management | Superior Gluteal Nerve Block | PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the ... | pain management, neurapraxia, impingement syndrome, neuralgia, superior gluteal, superior gluteal nerve block, gluteus medius muscle, gluteus maximus muscle, gluteus medius, nerve block, gluteal nerve, block, gluteus, nerve, gluteal |
1,960 | Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. | Pain Management | Radiofrequency Ablation | PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associat... | pain management, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle, |
1,961 | Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain. | Pain Management | Radiofrequency Thermocoagulation - 1 | PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: ,INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile f... | pain management, lumbar sympathetic chain, vertebral body, radiofrequency thermocoagulation, motor stimulation, thermocoagulation, radiofrequency, coagulation, needle, |
1,962 | Complex regional pain syndrome, right upper extremity. Stellate ganglion block. | Pain Management | Stellate Ganglion Block | PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION:, | pain management, chassaignac's tubercle, horner's sign, stellate ganglion block, sheath, vertebral, stellate, ganglion, cervical, block, |
1,963 | Pain management sample progress note. | Pain Management | Pain Management Progress Note | DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox inj... | pain management, progress note, management, muscle |
1,964 | Injection of Morton's neuroma. | Pain Management | Mortons Neuroma Injection | POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours. | pain management, injection, depo-medrol, morton's neuroma, gauge needle, inflammation, metatarsal ligament, metatarsal space, neuroma, redness, swelling, morton'sNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not... |
1,965 | Cervical spondylosis. Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami. | Pain Management | Radiofrequency Thermocoagulation - 3 | PREOPERATIVE DIAGNOSIS:, Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis.,OPERATION PERFORMED:, Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:, Ralph Menard, M.D.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCED... | pain management, rami, fluoroscopic control, radiofrequency thermocoagulation, cervical spondylosis, articular pillars, motor stimulation, medial branch, thermocoagulation, rftc, needle, cervical, stimulation |
1,966 | Right sacral alar notch and sacroiliac joint/posterior rami injections with/without fluoroscopy. | Pain Management | Sacral Alar Notch Injection | PROCEDURE:, Right sacral alar notch and sacroiliac joint/posterior rami injections with fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: ,None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room with intravenous line in place and intravenous sedat... | pain management, fluoroscopy, sacroiliac joint, sacral alar notch, posterior rami, sacroiliac, alar, sacral, notch, |
1,967 | Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection. | Pain Management | Neuroplasty | PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibr... | pain management, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural, |
1,968 | Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph. | Pain Management | Radiofrequency Thermocoagulation - 2 | PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side.,2. Interpretation of Radiograph.,ANESTHESIA: ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None... | pain management, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion, |
1,969 | Plantar Fascia Injection | Pain Management | Plantar Fascia Injection | PROCEDURE:,: Informed consent was obtained from the patient. Special mention was made of the possibility of infection and necrosis of the heel pad. The patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation with antiseptic s... | pain management, plantar fascia injection, plantar fascia, calcaneus, heel pad, necrosis, depo-medrol, bandage, medial aspect, heel, syringe, injection, needleNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not ce... |
1,970 | Lumbar epidural steroid injection, L5-S1. Low back pain. | Pain Management | Lumbar Epidural Steroid Injection - 2 | PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE: , Lumbar epidural steroid injection, L5-S1.,ANESTHESIA: , Local.,SPECIAL EQUIPMENT: , Fluoroscopic unit.,DETAILS OF PROCEDURE: , The patient was taken to the Radiology Suite and was placed in the prone position where the entir... | pain management, back pain, lumbar epidural steroid injection, tuohy needle, steroid injection, subcutaneous, epidural, steroid, lumbar, sterile, injection |
1,971 | Lumbar epidural steroid injection for lumbar radiculopathy. | Pain Management | Lumbar Epidural Steroid Injection - 3 | PREOPERATIVE DIAGNOSIS: ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:, Lumbar radiculopathy, 724.4.,PROCEDURE:, Lumbar epidural steroid injection.,ANESTHESIOLOGIST:, Monitored anesthesia care,INJECTATE USED:, 10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, ... | pain management |
1,972 | Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. | Pain Management | Medial Branch Rhizotomy | PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include... | pain management, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy, |
1,973 | Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain. | Pain Management | Lumbar Discogram | PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1. Lumbar discogram L2-3.,2. Lumbar discogram L3-4.,3. Lumbar discogram L4-5.,4. Lumbar discogram L5-S1.,ANESTHESIA: ,IV sedation.,PROCEDURE IN DETAIL: ,The patient was brought to the Radiology Suite and placed... | pain management, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle, |
1,974 | Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. | Pain Management | Lumbar Epidural Steroid Injection | PROCEDURE:, Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS:, See nurse's records.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE:, INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal ma... | pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection, |
1,975 | Bilateral lumbar sympathetic block. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored. | Pain Management | Lumbar Sympathetic Block | PROCEDURE:, Bilateral lumbar sympathetic block.,ANESTHESIA: , Local sedation.,VITAL SIGNS:, See nurse's notes.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored. Xylocaine 1.5% for sk... | pain management, transverse process, fluoroscopic guidance, lateral projection, lumbar sympathetic block, vertebral body, sympathetic, betadine, needle, aspiration, lumbar, |
1,976 | Osteoarthritis of the right knee. Right knee joint steroid injection. | Pain Management | Knee Injection - 1 | PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:, Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:, Osteoarthritis of the right knee.,PROCEDURE: ,The patient was apprised of the risks and the benefits of the procedure and consented. The patient's right knee was sterilely prepped wi... | pain management, injection, knee joint, steroid injection, osteoarthritis, knee |
1,977 | Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis. | Pain Management | Lumbar Facet Injections | PREOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,OPERATION PERFORMED:, Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After proper consent was obtained, the patient was taken to the fluo... | pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet |
1,978 | Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe. | Pain Management | Lumbar Epidural Steroid Injection - 1 | OPERATION:, Lumbar epidural steroid injection, intralaminar approach, seated position.,ANESTHESIA:, | pain management, loss of resistance technique, methylprednisolone acetate, lumbar epidural steroid injection, epidural steroid injection, tuohy needle, steroid injection, epidural space, intralaminar approach, injection, intralaminar, saline, epidural |
1,979 | Evaluation for right L4 selective nerve root block. | Pain Management | Lower Extremity Pain | REASON FOR REFERRAL:, Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:, | null |
1,980 | She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee. | Pain Management | Knee Injection - 2 | INDICATIONS FOR PROCEDURE: , The patient was here for joint injection. She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. What bother her the most is the joint swelling of her left knee ... | pain management, arthralgias, aristospan, pauciarticular arthritis, joint injection, injection, swelling, arthritis, joints, kneeNOTE,: 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 ... |
1,981 | Intercostal block from fourth to tenth intercostal spaces, left. Chest pain secondary to fractured ribs, unmanageable with narcotics. | Pain Management | Intercostal block - 1 | PREPROCEDURE DIAGNOSIS:, Chest pain secondary to fractured ribs, unmanageable with narcotics.,POSTPROCEDURE DIAGNOSIS:, Chest pain secondary to fractured ribs, unmanageable with narcotics.,PROCEDURE: , Intercostal block from fourth to tenth intercostal spaces, left.,INDICATIONS: , I was requested by Dr. X to do an in... | pain management, xylocaine, marcaine, intercostal spaces, intercostal block, fractured ribs, intercostal, fractured, narcotics, chest, |
1,982 | Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The patient is a 78-year-old female with back pain referring into the left side. | Pain Management | Kenalog Injection | PROCEDURE:, Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.,INDICATIONS: ,The patient is a 78-year-old female with back pain referring into the left side. She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralam... | pain management, transforaminal approach, epidural steroid injection, nerve root, needle tip, kenalog, transforaminal, fluoroscopic, guidance, foraminal, injection |
1,983 | Knee injection | Pain Management | Knee Injection | The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours. The patient was advised to protect the knee by limiting repetitive bending, squatting , kneeling and excessive heavy use for a week.... | pain management, knee injection, hibistat, xylocaine, bending, epinephrine, knee joint, kneeling, needle, patella, squatting, superolateral approach, cleansed, kneeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does n... |
1,984 | Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine. | Pain Management | Hip Injection | PROCEDURE: , Hip injection.,INFORMED CONSENT: ,The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, a... | pain management, boney landmarks, fluoroscopy, femoral artery, planned needle approach, hip injection, injection, hip, needle |
1,985 | Standard hypogastric plexus block procedure note. | Pain Management | Hypogastric Plexus Block | NAME OF PROCEDURE:, Hypogastric plexus block.,ANESTHESIA:, Local.,PROCEDURE: , The patient was in the operating room in the prone position with the back prepped and draped in sterile fashion. Local anesthesia was used to make a skin wheal 8-10 cm lateral to the L4 spinous process bilaterally from the midline. Start... | pain management, vertebral body, fluoroscopic view, omnipaque, hypogastric plexus blockNOTE |
1,986 | Caudal epidural steroid injection without fluoroscopy. | Pain Management | Epidural Steroid Injection - 2 | PROCEDURE: ,Caudal epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS: , See nurse's records.,PROCEDURE DETAILS: , INT was placed. The patient was in the prone position. The back was prepped with Betadine. Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus. A... | pain management, epidural space, epidural steroid injection, caudal epidural, caudal, fluoroscopy, steroid, epidural, injection |
1,987 | Intercostal block, left. Severe post thoracotomy pain. | Pain Management | Intercostal Block | PREOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,POSTOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,PROCEDURE: , Intercostal block, left.,PROCEDURE DETAIL: , With the patient in the ICU bed who was having a large amount of intravenous narcotic to control his thoracotomy pain, after obtaining informed conse... | pain management, thoracotomy pain, intercostal block, marcaine, thoracotomy, intercostal, |
1,988 | Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain. | Pain Management | Facet Arthrogram & Injection | PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.... | pain management, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet, |
1,989 | Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated. | Pain Management | Epidural Steroid Injection - 3 | PROCEDURE NOTE:, The patient was placed in a prone position. The neck was sterilely prepped using a cervical prep set. A lidocaine skin wheal was raised over the C5-6 interspace. A 20-gauge Tuohy needle was used. Loss of resistance was obtained using hanging drop technique. This was followed by 2 mL of radiograph... | pain management, methylprednisolone acetate, steroid, bupivacaine, methylprednisolone, acetate, epidural, injectionNOTE,: 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... |
1,990 | L3-L5 epidural steroid injection with epidural catheter under fluoroscopy. | Pain Management | Epidural Steroid Injection - 1 | PREOPERATIVE DIAGNOSIS:, Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: ,Th... | pain management, epidural catheter, epidural steroid injection, lumbar disk, steroid injection, fluoroscopy, herniated, lumbar, needle, steroid, epidural, catheter, injection |
1,991 | Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping. | Pain Management | Epidurogram | PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION... | pain management, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle |
1,992 | Transforaminal epidural steroid block with fluoroscopy. | Pain Management | Epidural Steroid Block | DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2. Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3. Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room. ... | pain management, c-arm, epidural steroid block with fluoroscopy, sciatica, transforaminal, steroid block with fluoroscopy, epidural steroid block, depo medrol, transforaminal epidural, steroid block, fluoroscopy, epidural, intravenous, steroid, |
1,993 | Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were ... | Pain Management | Dorsal Ramus & Branch Block | PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its... | pain management, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block, |
1,994 | Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe. | Pain Management | Epidural Blood Patch | OPERATION:, | pain management, epidural space, loss of resistance technique, epidural blood patch, tuohy needle, tourniquet, epidural |
1,995 | Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy. | Pain Management | Epidural Steroid Injection | PRE-OP DIAGNOSES:, Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,POST-OP DIAGNOSES: , Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,INTERVAL HISTORY:, Plans, risks and options were reviewed with the patient in detail. The patient und... | pain management, back pain, herniated disc, lumbosacral facet, epidural needle, lumbosacral facet arthropathy, epidural steroid injection, facet arthropathy, epidural space, injection, epidurogram, fluroscopy, herniated, lumbosacral, steroid, arthropathy, epidural, |
1,996 | Cervical Selective Nerve Root Block | Pain Management | Cervical Selective Nerve Root Block | CERVICAL SELECTIVE NERVE ROOT BLOCK,PREPROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was u... | pain management, nerve root block, 1% lidocaine, asa monitors, cervical selective nerve root block, fluoroscopy, iv sedation, nerve root, oblique, selective nerve root, carotid artery, foramen, neural foramina, edge of the foramen, selective nerve root block, cervical, |
1,997 | Coccygeal injection | Pain Management | Coccygeal injection | COCCYGEAL INJECTION,PROCEDURE:,: Informed consent was obtained from the patient. A gloved little finger was inserted into the anal region and the sacral/coccygeal joint was palpated and the coccyx was moved and it was confirmed that this reproduced pain. After aseptic cleaning, a 25-gauge needle was inserted through... | pain management, coccygeal injection, 0.25% marcaine, 1 ml of cortisone, coccygeal joint, coccyx, fevers, inflammation, redness, sacral, swelling, coccygeal, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine doe... |
1,998 | Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control. | Pain Management | Cervical Medial Branch Blocks | PREOPERATIVE DIAGNOSIS:, Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis.,OPERATION PERFORMED:, Cervical Medial Branch Blocks under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE:, After proper consent was obtained, the patient was taken to the... | pain management, fluoroscopic control, fluoroscopy, cervical medial branch blocks, medial branch blocks, cervical spondylosis, articular pillars, cervical, anesthesia, spondylosis, fluoroscopic, blocks, needle, medial, branch, |
1,999 | Costochondral Cartilage Injection | Pain Management | Costochondral Cartilage Injection | COSTOCHONDRAL CARTILAGE INJECTION,PROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the supine position.,Intravenous access was established. The patient was given mild narcotics for sedation. For fu... | pain management, costochondral cartilage injection, 0.5% marcaine, ap and lateral, costochondral, depo-medrol, costochondral junction, fluoroscopy, hypodermic needle, pneumothorax, subcutaneously, supine position, cartilage injection, costochondral cartilage, needle, distress, cartilage, injection, |
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