Unnamed: 0 int64 0 5k | description stringlengths 1 492 | medical_specialty stringlengths 8 30 | sample_name stringlengths 5 69 | transcription stringlengths 11 18.4k ⌀ | keywords stringlengths 1 916 ⌀ |
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2,000 | Caudal epidural steroid injection | Pain Management | Caudal Epidural Steroid Injection | CAUDAL EPIDURAL STEROID INJECTION,PROCEDURE:,:,1. Caudal epidural steroid injection with contrast.,2. Utilization of fluoroscopy for confirmation of needle placement.,PREPROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The ... | pain management, steroid injection, 1% lidocaine, ap and lateral, asa monitors, caudal epidural steroid injection, epidural, fluoroscopy, ligament, needle placement, sacral hiatus, sacrococcygeal, caudal epidural, epidural steroid, caudal, steroid, injection, |
2,001 | Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique. | Pain Management | Cervical Epidural Steroid Injection | PROCEDURE:, Cervical 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. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% wa... | pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, injection, |
2,002 | Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance. The patient is a 51-year-old female with back pain referring into the right leg. | Pain Management | Depo-Medrol Injection | PROCEDURE: , Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.,INDICATION: , The patient is a 51-year-old female with back pain referring into the right leg.,RISKS VERSUS BENEFITS: , The risks and benefits were discussed with the patient prior to the procedure. ... | pain management, epidural steroid injection, fluoroscopic guidance, depo medrol, injection |
2,003 | Standard celiac plexus block procedure note. | Pain Management | Celiac Plexus Block | NAME OF PROCEDURE: , Celiac plexus block.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,PROCEDURE: , INT was placed. The patient was in the prone position back prepped and draped in sterile fashion. Then 1.5% of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1-L2 vertebral junction. ... | pain management, omnipaque, vertebral body, puncture sites, celiac plexus block, celiac, plexus, block, vertebral |
2,004 | Cervical epidural steroid injection, C5-6. The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level. | Pain Management | Cervical Epidural Steroid Injection - 2 | PROCEDURE PERFORMED:, Cervical epidural steroid injection, C5-6.,ASSISTANT:, None.,ANESTHESIA:, Local.,DETAILS OF PROCEDURE: , The patient was brought to the operating theater and placed prone onto the radiolucent table. Subsequent monitored anesthesia care was administered. The C-arm was brought into the operativ... | pain management, c-arm, cervical epidural steroid injection, ap view, lumbar spine, tuohy needle, epidural steroid, steroid injection |
2,005 | Cervical facet joint injection with contrast | Pain Management | Cervical Facet Joint Injection | CERVICAL FACET JOINT INJECTION WITH CONTRAST.,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 sedat... | pain management, injection, 1% lidocaine, asa monitors, cervical, cervical facet joint injection, celestone, facet joint, facet joint injection, fluoroscopy, iv sedation, facet joints, spinal needle, cervical facet joint, joint injection, joint, facetNOTE,: Thesetranscribed medical transcription sample reports and exam... |
2,006 | Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach. | Pain Management | Cervical Epidural Steroid Injection - 1 | OPERATION PERFORMED: , Cervical epidural steroid injection C7-T1.,ANESTHESIA:, Local and Versed 2 mg IV.,COMPLICATIONS: ,None.,DESCRIPTION OF PROCEDURE: ,The patient was placed in the seated position with the neck flexed the forehead was placed on a cervical rest. The head and cervical spine were restrained. The p... | pain management, tuohy needle, cleansing solution, epidural space, loss of resistance, cervical epidural steroid injection, resistance technique, steroid injection, injection, intralaminar, steroid, epidural, |
2,007 | Acromioclavicular joint injection | Pain Management | Acromioclavicular Joint Injection | ACROMIOCLAVICULAR JOINT INJECTION,PROCEDURE:,: Informed consent was obtained from the patient. All possible complications were mentioned including joint swelling, infection, and bruising. The joint was prepared with Betadine and alcohol. Then 1 mL of Depo-Medrol and 2 mL of 0.25% Marcaine were injected using the an... | pain management, acromioclavicular joint injection, acromioclavicular, betadine, depo-medrol, alcohol, fevers, inflammation, intravascular injection, joint injection, redness, swelling, acromioclavicular joint, injection, jointNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by var... |
2,008 | Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot. | Orthopedic | Youngswick Osteotomy | TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:, Monitored anesthesia care wit... | orthopedic, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy |
2,009 | Injection of bilateral carpal tunnels | Pain Management | Bilateral Carpal Tunnels 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. carpal tunnel, bilateral carpal tunnels, inflammation, longus tendon, palmaris longus, palmaris longus tendon, redness, rolled-up towel, swelling, volar aspect, wrist, wrist crease, bilateral carpal, carpal tunnels, paresthesias, carpal, tunnels, towelNOTE,: Thesetranscribed medical transcri... |
2,010 | Bilateral sacroiliac joint injections | Pain Management | Bilateral sacroiliac joint injections | BILATERAL SACROILIAC JOINT INJECTIONS,PROCEDURE:,: Informed consent was obtained from the patient. The patient was placed in the prone position. After preparation and local anesthetic administration, and image intensifier control a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint ... | pain management, bilateral sacroiliac joint injections, 0.25% marcaine, celestone, postprocedure, fevers, image intensifier, inflammation, posterior approach, redness, sacroiliac joint, spinal needle, swelling, bilateral sacroiliac joint, sacroiliac joint injections, sacroiliac, injectionsNOTE,: Thesetranscribed medica... |
2,011 | Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot. | Orthopedic | Youngswick Bunionectomy | PREOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1. Austin/Youngswick bunionectomy with Biopro implant.,2. Screw fixation, left foot.,HISTORY: , This 5... | orthopedic, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw, |
2,012 | Consultation for wrist pain. | Orthopedic | Wrist Pain | CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:, | orthopedic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar, |
2,013 | Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. | Orthopedic | Wrist Ganglion Excision | PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguina... | orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion |
2,014 | Unilateral transpedicular T11 vertebroplasty. | Orthopedic | Vertebroplasty | PREOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,OPERATION PERFORMED:, Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:, Local with IV sedation.,COMPLICATIONS:, None.,SUMMARY: , The patient in the operating r... | orthopedic, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle |
2,015 | Trigger point injections with Botox. | Pain Management | Botox Injection - Trigger Point | PROCEDURE PERFORMED: , Trigger point injections with Botox.,PREPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothy... | null |
2,016 | Greater trochanteric bursal injection. | Pain Management | Bursal Injection | null | pain management, greater trochanteric, depo-medrol, hibistat, bursal injection, excessive heavy use, lateral decubitus position, mid-trochanter, needle, no touch technique, spinal needle, trochanteric, xylocaine, bursal, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by ... |
2,017 | Trigger thumb release. Right trigger thumb. The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release). | Orthopedic | Trigger Thumb Release - 1 | PREOPERATIVE DIAGNOSIS: ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,OPERATIONS PERFORMED:, Trigger thumb release.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:, | orthopedic, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger, |
2,018 | Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis. | Orthopedic | Ulnar Nerve Transposition & Olecranon Bursa Excision | PREOPERATIVE DIAGNOSIS: ,1. Right cubital tunnel syndrome.,2. Right carpal tunnel syndrome.,3. Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Right cubital tunnel syndrome.,2. Right carpal tunnel syndrome.,3. Right olecranon bursitis.,PROCEDURES:, ,1. Right ulnar nerve transposition.,2. Right carpal... | orthopedic, cubital tunnel syndrome, carpal tunnel syndrome, olecranon bursitis, ulnar nerve transposition, carpal tunnel release, excision of olecranon bursa, transposition, ligament, tourniquet, excision, bursa, syndrome, subcutaneous, ulnar, olecranon, carpal, nerve, tunnel, |
2,019 | Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. | Orthopedic | Ulnar Nerve Transposition | PROCEDURE:, Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision w... | orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve |
2,020 | Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vi... | Orthopedic | Trigger Finger Release | PROCEDURE: , Trigger finger release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made over th... | orthopedic, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision |
2,021 | Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment. | Orthopedic | Ulnar Nerve Decompression | PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:, The ulnar nerve appeared to be s... | orthopedic, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel |
2,022 | Total knee replacement. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed. | Orthopedic | Total Knee Replacement - 1 | PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, a tourniquet was placed on the upper thigh. Sterile prepping and draping proceeded. The tourniquet was inflated to 300 mmHg. A midline incisio... | orthopedic, proximal medial tibia, total knee replacement, parapatellar arthrotomy, subcutaneous tissues, tibial plateau, incision, cutting, patella, femur, femoral, component, knee, |
2,023 | Right total knee arthroplasty - Osteoarthritis, right knee. | Orthopedic | Total Knee Arthroplasty - Right | PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, a... | orthopedic, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia, |
2,024 | Total left knee replacement. Degenerative arthritis of the left knee. Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. | Orthopedic | Total Knee Replacement | PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03. The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X... | orthopedic, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation, |
2,025 | Trigger thumb release. A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. | Orthopedic | Trigger Thumb Release | PROCEDURE: ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MP... | orthopedic, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision |
2,026 | Right knee total arthroplasty. Degenerative osteoarthritis, right knee. | Orthopedic | Total Knee Arthroplasty | PREOPERATIVE DIAGNOSIS:, Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL ... | orthopedic, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill, |
2,027 | Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy. | Orthopedic | Transpedicular Decompression | PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1. Foraminal disc herniation of left L3-L4.,2. Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:, General.,COMPLICATIONS:... | orthopedic, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal |
2,028 | Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. | Orthopedic | Total Hip Arthroplasty | PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED: ,Total hip arthroplasty on the left.,ANESTHESIA: ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 5... | orthopedic, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty, |
2,029 | Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. | Orthopedic | Total Hip Replacement - 1 | PROCEDURE:, Total hip replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, the patient was turned on the side and secured in the hip table. An incision was made, centered over the greater trochanter. Dissection was sharp... | orthopedic, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur |
2,030 | Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G. | Orthopedic | Total Knee Arthoplasty - Right - 1 | PREOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:, Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, ... | orthopedic, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial, |
2,031 | Right hip osteoarthritis. Total hip replacement on the right side. | Orthopedic | Total Hip Replacement | PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2. Trabecular metal mo... | orthopedic, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostas... |
2,032 | NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. | Orthopedic | Total Knee Replacement - NexGen | PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: Approximately 66 minutes.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,... | orthopedic, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella |
2,033 | Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device. | Orthopedic | TLIF | PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TL... | orthopedic, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space,... |
2,034 | Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty. | Orthopedic | Total Hip Arthroplasty - Revision | PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:, Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1. Removal of antibiotic spacer.,2. Revision total hip ar... | orthopedic, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur, |
2,035 | History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle. Insertion of tissue expander to the medial and lateral wound. | Orthopedic | Tissue Expander Insertion | PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fas... | orthopedic, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment, |
2,036 | Pain. Three views of the right ankle. Three views of the right ankle are obtained. | Orthopedic | 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... | orthopedic, three views, calcaneal, plantar, spur, osseous, ankle |
2,037 | Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. | Orthopedic | 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... | orthopedic, three views, radiopaque, fractures, foot trauma |
2,038 | Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm. | Orthopedic | 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... | orthopedic, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone, |
2,039 | Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot. | Orthopedic | 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,... | orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone |
2,040 | Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot. | Orthopedic | Tailor Bunionectomy with Screw Fixation | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,PROCEDURES PERFORMED: ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANEST... | orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis, |
2,041 | 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. | Orthopedic | 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... | orthopedic, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux |
2,042 | Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty. | Orthopedic | Synovectomy - Partial | PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,DRAINS:, None.,INDIC... | orthopedic, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy, |
2,043 | Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion. | Orthopedic | Styloidectomy | PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate ... | orthopedic, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass |
2,044 | Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots. | Orthopedic | Spinal Fusion & Instrumentation | PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General. Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1. Posterior spinal fusion from T2-L2.,2. Posterior spinal instrumentation from T2-L2.,3. A posterior osteotomy through T7-T8 and T8-T9. Posterior elements to include laminotomy-for... | orthopedic, osteotomy, laminotomy-foraminotomy, sofamor danek, sseps, spinal fusion, transverse processes, pedicle hooks, pedicle, laminotomy, hooks, screws, instrumentation, decompression, scoliosis, sofamor, foraminotomy, spinal |
2,045 | Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. | Orthopedic | Thoracic Discectomy | PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to... | orthopedic, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated, |
2,046 | Repeat irrigation and debridement of Right distal femoral subperiosteal abscess. | Orthopedic | Subperiosteal Abscess Debridement | PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:, Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:, Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , Non... | orthopedic, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess, |
2,047 | Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome. | Orthopedic | Subcutaneous Transposition of Ulnar Nerve | PREOPERATIVE DIAGNOSIS: ,1. Right carpal tunnel syndrome.,2. | orthopedic, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel |
2,048 | Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft. | Orthopedic | Spine Fusion | PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES: ,1. Anterior spine fusion from T11-L3.,2. Posterior spine fusion from T3-L5.,3. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autogr... | orthopedic, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft, |
2,049 | Superior labrum anterior and posterior lesion repair. | Orthopedic | Superior Labrum Lesions Repair | PROCEDURE IN DETAIL:, After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder ... | orthopedic, laxity, patholigamentous, superior labrum, saline solution, anterior, superior, lesions, repair, sterile, joint, shoulder, |
2,050 | Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis. | Orthopedic | Spinal Manipulation | PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (73... | orthopedic, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar, |
2,051 | Frontal and lateral views of the hip and pelvis. | Orthopedic | 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 ... | orthopedic, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip |
2,052 | Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy. | Orthopedic | Rotator Cuff Repair | PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1. Sixty-percent rotator cuff tear, joint side.,2. Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1. Arthroscopic subacromial decompression.,2. Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The pat... | orthopedic, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator,... |
2,053 | Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder. | Orthopedic | Shoulder Contusion | CHIEF COMPLAINT: , | orthopedic, shoulder, injury, two views, shoulder contusion, |
2,054 | Consultation for right shoulder pain. | Orthopedic | Shoulder Pain Consult | CHIEF COMPLAINT:, Right shoulder pain.,HISTORY OF PRESENT PROBLEM: | orthopedic, shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder, |
2,055 | Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. | Orthopedic | Rotator Cuff Tear | REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y... | orthopedic, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical, |
2,056 | Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot. | Orthopedic | Scarf Bunionectomy | PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:, IV sedation with local.,HISTORY: , Th... | orthopedic, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus |
2,057 | Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder. | Orthopedic | Shoulder Hemi-resurfacing | PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTI... | orthopedic, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder, |
2,058 | Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease. | Orthopedic | Right Shoulder Hemiarthroplasty | PREOPERATIVE DIAGNOSES:,1. Right shoulder rotator cuff tear.,2. Glenohumeral rotator cuff arthroscopy.,3. Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1. Right shoulder rotator cuff tear.,2. Glenohumeral rotator cuff arthroscopy.,3. Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarth... | orthopedic, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder, |
2,059 | Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right. | Orthopedic | Rotator cuff syndrome - H&P | CHIEF COMPLAINT: ,This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity... | null |
2,060 | Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb. | Orthopedic | Release of A1 Pulley - 1 | PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:, Release of A1 pulley, right thumb.,ANESTHESIA:, IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQU... | orthopedic, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley |
2,061 | Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine. | Orthopedic | Rheumatology Progress Note | SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. S... | orthopedic, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected, |
2,062 | The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley. | Orthopedic | Release of A1 Pulley | PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:, General LMA.,TOURNIQUET TIME: ,9 minutes at 200 torr.,FINDINGS:, The patient was found to have limitations to extension at the IP joint to the right thumb. He ... | orthopedic, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint |
2,063 | Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion. | Orthopedic | PMT Halo Crown & Vest | PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERAT... | orthopedic, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical, |
2,064 | A sample note on RICE Therapy | Orthopedic | RICE Therapy | RICE, stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation.,REST:,Stop using the injured part as soon as you realize that an injury has taken place. Use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. Use splints for injuries of the... | orthopedic, rest, ice, compression, and elevation, foot, ankle, knee, leg, splints, hand, wrist, elbow, arm, ace bandage, compression and elevation, rice therapy, compression bandage, ice packs, rice, elevation, swelling, bandage, therapy |
2,065 | Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain. | Orthopedic | Radiologic Exam - Spine | EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS: ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. | orthopedic, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebr... |
2,066 | Closed reduction and pinning of the right ulna with placement of a long-arm cast. | Orthopedic | Pinning - Ulna | PREOPERATIVE DIAGNOSIS:, Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marca... | orthopedic, closed reduction, pinning, forearm refracture, fracture site, arm cast, |
2,067 | Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose. | Orthopedic | Records Review - Orthopedic | Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work harden... | null |
2,068 | 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. | Orthopedic | 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... | orthopedic, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle, |
2,069 | External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fi... | Orthopedic | Pilon Fracture External Fixation | PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,... | orthopedic, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation, |
2,070 | Revision and in situ pinning of the right hip. | Orthopedic | Pinning - Hip | PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS: ,There were no in... | orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw, |
2,071 | Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux. | Orthopedic | 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... | orthopedic, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal |
2,072 | Open repair of right pectoralis major tendon. Right pectoralis major tendon rupture. On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted. | Orthopedic | Pectoralis Tendon Repair | PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:, General with an interscalene block.,COMPLICATIONS:, None.,Needle and sponge counts were done and correct.... | orthopedic, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures, |
2,073 | 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. | Orthopedic | 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 |
2,074 | Specimen labeled "sesamoid bone left foot". | Orthopedic | Pathology - Sesamoid Bone | GROSS DESCRIPTION: , Specimen labeled "sesamoid bone left foot" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is entirely submi... | orthopedic, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: 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 tra... |
2,075 | 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. | Orthopedic | 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 |
2,076 | 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... | Orthopedic | 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 |
2,077 | A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. | Orthopedic | 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... | orthopedic, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, |
2,078 | 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. | Orthopedic | 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 |
2,079 | Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee. | Orthopedic | Patellar Tendon & Retinaculum Repair | PREOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS: ,Intraoperative procedure done at Inpatient Operative S... | orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum |
2,080 | 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... | Orthopedic | 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 |
2,081 | Pain management sample progress note. | Orthopedic | 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... | orthopedic, progress note, management, muscle |
2,082 | Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot. | Orthopedic | Osteotomy & Bunionectomy | PREOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1. D... | |
2,083 | Pain management for post-laminectomy low back syndrome and radiculopathy. | Orthopedic | Pain Management Consult - 1 | Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history bec... | orthopedic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome, |
2,084 | Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time... | Orthopedic | Osteotomy & Bunionectomy - 1 | PREOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,PROCEDURE PERFORMED:,1. Third metatarsal osteotomy, right foot.,2. Talus bunionectomy, right foot.,3. Application ... | orthopedic, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy |
2,085 | Orthopedic progress note for follow up of osteoarthritis, knees. | Orthopedic | Osteoarthritis - Progress Note | CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain: Localized to the bi... | null |
2,086 | OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis. | Orthopedic | OssaTron Extracorporeal Shockwave Therapy | PREOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,OPERATION PERFORMED:, OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:, Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the pa... | orthopedic, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave, |
2,087 | Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement. | Orthopedic | Osteosynthesis | PREOPERATIVE DIAGNOSIS:, Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:, Acetabular fracture on the left posterior column/transverse posterior wall variety with an acc... | orthopedic, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral |
2,088 | Patient with back and hip pain. | Orthopedic | Orthopedic Consult - 5 | Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppress... | null |
2,089 | Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. | Orthopedic | Orthopedic Consult - 4 | CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, ... | orthopedic, radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement |
2,090 | Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs | Orthopedic | Orthopedic Consult - 3 | CHIEF COMPLAINT:, Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:, The patient is on my schedule today to explore treatment of the above complaints. She has a two-year history of small cell lung cancer, which she says has spre... | null |
2,091 | Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty. | Orthopedic | Orthopedic Consult - 2 | SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain. She has a history of prior laminectomy for spinal stenosis. She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, an... | orthopedic, scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, ... |
2,092 | Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left. | Orthopedic | Pain Management Consult - 2 | HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing... | null |
2,093 | Medical management, status post left total knee arthroplasty. | Orthopedic | Orthopedic Consult | REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bil... | null |
2,094 | Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome. | Orthopedic | Orthopedic Consult - 1 | SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radicu... | orthopedic, low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anseri... |
2,095 | A 19-year-old right-handed male injured in a motor vehicle accident. | Orthopedic | Ortho - Letter - 1 | XYZ, D.C.,Re: ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side. The... | orthopedic, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho, |
2,096 | Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius. | Orthopedic | ORIF Wrist - Acumed Locking Plate | PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal ... | orthopedic, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist |
2,097 | The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints. | Orthopedic | Ortho Office Visit | Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal ... | orthopedic, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accura... |
2,098 | Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3. | Orthopedic | ORIF & Cervical Fusion | PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS: ,Fracture dislocation, C2.,OPERATION PERFORMED,1. Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2. Posterior spinal instrumentation C1-C3, using Synthes system.,3. Posterior cervical fusion C1-C3.,4. Insertion of ... | orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation, |
2,099 | Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm. | Orthopedic | ORIF & Closed Reduction | PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:, Left elbow fracture dislocation with incarceration of the media... | orthopedic, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar ne... |
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