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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2,400 | Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye. | Ophthalmology | Phacoemulsification & Lens Implantation - 3 | PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE:, Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:, None,SPECIMENS:, None,PROCEDURE IN DETAIL: , The patient had ... | ophthalmology, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular |
2,401 | Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. | Ophthalmology | Phacoemulsification & Lens Implantation - 2 | PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE: ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops. Topical anesthetic drops were applied t... | ophthalmology, keratome, phacoemulsification, cortex, tobradex, intraocular lens, aspiration unit, topical, chamber, viscoelastic, corneal, capsular, lens, intraocular, eye, |
2,402 | Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. Cataract, right eye. | Ophthalmology | Phacoemulsification & Cataract Extraction - 4 | PREOPERATIVE DIAGNOSIS: ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS: ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCED... | ophthalmology, provisc, intraocular lens implantation, intraocular lens, lens implantation, lid speculum, capsular bag, cataract extraction, phacoemulsification, cataract, intraocular |
2,403 | Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and le... | Ophthalmology | Phacoemulsification & Cataract Extraction - 1 | PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS:... | ophthalmology, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, surgery, chamber, phacoemulsification, extraction, visually, anterior, lens |
2,404 | Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye. | Ophthalmology | Phacoemulsification & Lens Implantation | PREOPERATIVE DIAGNOSIS:, Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO ... | ophthalmology, nuclear sclerotic, diopters, viscoelastic, capsulorrhexis, amvisc plus, lens implantation, intraocular lens, intraocular, topical, cataract, phacoemulsification, lens |
2,405 | Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye. | Ophthalmology | Phacoemulsification & Cataract Extraction | DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5... | ophthalmology, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE |
2,406 | Visually significant nuclear sclerotic cataract, right eye. Phacoemulsification with posterior chamber intraocular lens implantation, right eye. | Ophthalmology | Phacoemulsification & Lens Implantation - 1 | PREOPERATIVE DIAGNOSIS:, Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:, Monitored anesthesia car... | ophthalmology, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar, |
2,407 | Nuclear sclerotic cataract, right eye. Kelman phacoemulsification with posterior chamber intraocular lens, right eye. | Ophthalmology | Phacoemulsification - Kelman | PREOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:, Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:, Topical.,COMPLICATIONS:, None.,INDICATION: , This is a 40-year-old male... | ophthalmology, nuclear sclerotic cataract, intraocular lens, cataract, kelman phacoemulsification, sclerotic cataract, posterior chamber, capsular bag, eye, anesthesia, phacoemulsification |
2,408 | Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. | Ophthalmology | Phacoemulsification & Cataract Extraction - 5 | PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, right eye.,PROCEDURE PERFORMED: ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved i... | ophthalmology, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular, |
2,409 | Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. A wire lid speculum was inserted to keep the eye open and the eye rotated downward. | Ophthalmology | Phacoemulsification & Cataract Extraction - 3 | PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,TITLE OF OPERATION: ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where retrobul... | ophthalmology, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular |
2,410 | Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted. | Ophthalmology | Phacoemulsification & Cataract Extraction - 2 | PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops w... | ophthalmology, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular, |
2,411 | Ophthalmology followup visit note. | Ophthalmology | Ophthalmology Progress Note - 2 | A fluorescein angiogram was ordered at today's visit to rule out macular edema. We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress. A copy of the angiogram is enclosed for your records. | ophthalmology, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, lensesNOTE,: Thesetranscribed medi... |
2,412 | Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye. | Ophthalmology | Pars Plana Vitrectomy & Lensectomy | TITLE OF OPERATION:,1. Pars plana vitrectomy.,2. Pars plana lensectomy.,3. Exploration of exit wound.,4. Closure of perforating corneal scleral laceration involving uveal tissue.,5. Air-fluid exchange.,6. C3F8 gas.,7. Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of... | null |
2,413 | Phacoemulsification with posterior chamber intraocular lens - Sample/Template. | Ophthalmology | Phacoemulsification | PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and bene... | ophthalmology, phacoemulsification, acrysof, acrysof natural lens, acular, kuglen hook, ocuflox, provisc, sn60at, senile cataract, thornton fixation ring, bleeding, capsular bag, decreased vision, diopters, diplopia, infection, loss of the eye, loss of vision, ptosis, retinal detachment, lid speculum, thornton fixation... |
2,414 | Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up. | Ophthalmology | Optometry - Letter | RE: Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY. She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year. She would like to get started with some vision therapy so that she may be ab... | ophthalmology, optometry, letter, optometry letter, pdt therapy, distance correction, macular degeneration, reading glasses, vision therapy, complete refractive, macular, degeneration, |
2,415 | Patient being referred for evaluation of glaucoma. | Ophthalmology | Ophthalmology - Letter - 2 | XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC. Mr. ABC is being referred for evaluation of glaucoma. The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally. The patient's visual fields are full to confronta... | ophthalmology, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact, |
2,416 | Patient referred for narrow angles and possible associated glaucoma. | Ophthalmology | Ophthalmology - Letter - 3 | XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma. I examined Mrs. ABC initially on MM/DD/YYYY. At that time, she expressed a chief concern of occasional pain around her eye, but denied any fla... | ophthalmology, intraocular pressures, narrow angles, visual fields, angles, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye, |
2,417 | The patient was referred for evaluation of cataracts bilaterally | Ophthalmology | Ophthalmology - Letter - 1 | XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC. The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye. Extraocular muscles were intact, visual fields were full to confronta... | ophthalmology, extraocular, applanations, slit lamp, visual field, visual, guttata, surgery, cataracts, eye, |
2,418 | The patient is being referred for evaluation of diabetic retinopathy. | Ophthalmology | Ophthalmology - Letter - 4 | XYZ, M.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC. The patient is being referred for evaluation of diabetic retinopathy. The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is s... | ophthalmology, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic, |
2,419 | Complete eye examination - Normal eye and vision exam. | Ophthalmology | Eye Examination - H&P | CHIEF COMPLAINT:, This 26-year-old male presents today for a complete eye examination.,ALLERGIES:, Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:, Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. Gener... | null |
2,420 | Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team. | Ophthalmology | Intraocular Lens Implant | TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/0... | ophthalmology, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye, |
2,421 | Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye | Ophthalmology | Nasolacrimal Probing | PREOPERATIVE DIAGNOSES:, Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES: ,1. Distal nasolacrimal duct stenosis with obstruction, left eye.,2. Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,AN... | ophthalmology, tearing, eyelash encrustation, tear duct obstruction, nasolacrimal duct stenosis, nasolacrimal, bowman probe, distal nasolacrimal duct, nasolacrimal probing, nasolacrimal duct, superior puncta, probe, obstruction, eyelash, duct, punctal, |
2,422 | Ophthalmology followup visit note. | Ophthalmology | Ophthalmology Progress Note - 1 | She is stable at this time and does not require any intervention at today's visit. I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision. | ophthalmology, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, acuitiesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various... |
2,423 | Repair of upper lid canalicular laceration - Sample/Template. | Ophthalmology | Lid Laceration Repair | PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMEN... | ophthalmology, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, ... |
2,424 | He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again. | Ophthalmology | Diplopia | HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dis... | null |
2,425 | Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position. | Ophthalmology | Electronystagmogram | PROCEDURE: ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze. Simultaneous recordings... | ophthalmology, silver chloride biopotential electrodes, inferior orbital margins, lateral canthi, vestibular dysfunction, prominent nystagmus, head hanging, electronystagmogram, eyes, nystagmus, |
2,426 | Difficulty with both distance vision and with fine print at near. | Ophthalmology | Difficulty Distance Vision & Fine Print at Near | REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient. He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:, Mr. ABC states that over the last year, he has had increasing difficulty with distance vi... | null |
2,427 | Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad. | Ophthalmology | Midface Lift & Blepharoplasty | PREOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,PROCEDURES:,1. Endoscopic subperiosteal midface lift using the endotine midface suspension d... | ophthalmology, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal, |
2,428 | Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye. | Ophthalmology | Clear Corneal Temporal Incision | CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's ... | ophthalmology, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not... |
2,429 | One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes. | Ophthalmology | Decreased Vision Consult | She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. She also has a history of glaucoma diagnosed in 1990 and macular degeneration. She has been followed in her home country and is here visiting family. She had the above-mentioned observation and was brought i... | ophthalmology, cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision, |
2,430 | Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid. | Ophthalmology | Eyelid Squamous Cell Carcinoma Excision | PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS: ,None.... | ophthalmology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis, |
2,431 | Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye. | Ophthalmology | Cataract Extraction & Vitrectomy | PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED: ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED: ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.... | ophthalmology, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens, |
2,432 | A sample note on Conjunctivitis (Pink Eye). | Ophthalmology | Conjunctivitis | CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid. It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1. Red, irritated eye.,2. Some burning and/or scratchy feeling.,3. There may be a purulent (pus) or a mucous type discharge.,H... | ophthalmology, eyelid, infected eyes, pink eye, conjunctivitis, eyes, infection, eye |
2,433 | Normal cataract surgery. | Ophthalmology | Cataract Surgery | NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Unde... | ophthalmology, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify... |
2,434 | She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism. | Ophthalmology | Connective Tissue Disorder | Her past medical history includes a presumed diagnosis of connective tissue disorder. She has otherwise, good health. She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically. She is allergic to penicillin.,The visual acuity today, distance... | ophthalmology, systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes |
2,435 | Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks. | Ophthalmology | Cataract Extraction Followup | Her past medical history includes insulin requiring diabetes mellitus for the past 28 years. She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease. She is scheduled to see a gastroenterologist in the near future. She is taking Econopred 8 times a day to the right eye and... | ophthalmology, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, cornealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcri... |
2,436 | Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. | Ophthalmology | Cataract Extraction - 1 | PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrin... | ophthalmology, phacoemulsification, hydrodissection, peribulbar block, irrigation and aspiration, honan balloon, anterior chamber, anterior capsular, aspiration unit, capsular bag, cataract extraction, intraocular lens, cataract, extraction, peribulbar, lidocaine, viscoelastic, chamber, epinephrine, anterior, capsular,... |
2,437 | A sample note on Cataract | Ophthalmology | Cataract | CATARACT, is the loss of transparency of the lens of the eye. It often appears like a window that is fogged with steam.,WHAT CAUSES CATARACT FORMATION?,* Aging, the most common cause.,* Family history.,* Steroid use.,* Injury to the eye.,* Diabetes.,* Previous eye surgery.,* Long-term exposure to sunlight.,HOW ... | ophthalmology, transparency, eye, sunlight, optic nerve, eye doctor, cataract, retina, lens, vision, surgery, |
2,438 | Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy. | Ophthalmology | Browlift, Blepharoplasty, & Rhytidectomy | PREOPERATIVE DIAGNOSES:,1. Eyebrow ptosis.,2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. Cervical facial aging with submental lipodystrophy.,OPERATION:,1. Hairline biplanar temporal browlift.,2. Quadrilateral blepharoplasty with lateral canthopexy with arcus margi... | ophthalmology, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds ... |
2,439 | Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded. | Ophthalmology | Cataract Extraction | PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adeq... | ophthalmology, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens |
2,440 | Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye. | Ophthalmology | Cataract Extraction - 2 | PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, left eye.,PROCEDURE PERFORMED: ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the inductio... | ophthalmology, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular, |
2,441 | Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging. | Ophthalmology | Blepharoplasty - Quad | PREOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,... | ophthalmology, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty, |
2,442 | The patient seeks evaluation for a second opinion concerning cataract extraction. | Ophthalmology | Cataract - Second Opinion | SUBJECTIVE: ,The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has... | ophthalmology, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract, |
2,443 | Blepharoplasty with direct brow repair. | Ophthalmology | Blepharoplasty - Direct Brow Repair | PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochala... | ophthalmology, dermatochalasis, erythromycin ophthalmic, saline gauze, blepharoplasty, brow ptosis, cold packs, direct brow lift, follicle growth, hemifield loss, marginal reflex, mechanical ptosis, ocular surface, superficial orbicularis, visual field, surgical marking pen, direct brow, redundant tissue, incision site... |
2,444 | Blepharoplasty procedure | Ophthalmology | Blepharoplasty | BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised ... | ophthalmology, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by va... |
2,445 | Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft. | Ophthalmology | BCCa Excision - Lower Lid | PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:, Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large p... | ophthalmology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival, |
2,446 | Lower lid blepharoplasty. | Ophthalmology | Blepharoplasty - Lower Lid | An orbital block was done. An infraorbital block was also performed with a 25 gauge needle. A skin muscle flap was elevated by sharp dissection down to the orbital rim area. The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out... | ophthalmology, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clampingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose on... |
2,447 | Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft. | Ophthalmology | Blepharon & Entropion Repair | PREOPERATIVE DIAGNOSES:,1. Entropion, left upper lid.,2. Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL: ... | ophthalmology, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane |
2,448 | Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis. | Ophthalmology | Bilateral Upper Lid Blepharoplasty | PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and r... | ophthalmology, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis |
2,449 | The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. | Ophthalmology | Ahmed Shunt Placement | PROCEDURE IN DETAIL: ,While in the holding area, the patient received a peripheral IV from the nursing staff. In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes. The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring l... | ophthalmology, cornea, ahmed shunt, nylon sutures, trabeculectomy, conjunctiva, chamberNOTE,: 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 t... |
2,450 | The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. | Office Notes | Telemetry Monitoring | DIAGNOSES PROBLEMS:,1. Orthostatic hypotension.,2. Bradycardia.,3. Diabetes.,4. Status post renal transplant secondary polycystic kidney disease in 1995.,5. Hypertension.,6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. History of renal osteodystrophy.,8. Iron deficiency ane... | office notes, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring, |
2,451 | Small office note on premature retina and vitreous. | Office Notes | Premature retina and vitreous | OCULAR FINDINGS: , Anterior chamber space: Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc spac... | office notes, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye, |
2,452 | Right hand laceration x3, repaired. | Office Notes | Right Hand Laceration | HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound w... | office notes, accutane, hand laceration, laceration, hand, |
2,453 | Underwent tonsillectomy and adenoidectomy two weeks ago. | Office Notes | Status Post T&A | SUBJECTIVE:, A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago. Also, I cleaned out his maxillary sinuses. Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue. The surgery went well, and I had planned for him to stay overnight, but ... | office notes, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses, |
2,454 | Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder. | Office Notes | Shoulder Contusion | CHIEF COMPLAINT: , | office notes, shoulder, injury, two views, shoulder contusion, |
2,455 | Quick note on tachypnea. | Office Notes | Tachypnea | null | office notes, chest, cpr, breath sounds, tachypnea, epinephrine, rhythmNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sam... |
2,456 | Sample post dilation patient instructions. | Office Notes | Post Dilation Instructions | The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help. | office notes, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: 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 transcrib... |
2,457 | The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago. | Office Notes | Status Post Tympanoplasty | The right eardrum is intact showing a successful tympanoplasty. I cleaned a little wax from the external meatus. The right eardrum might be very slightly red but not obviously infected. The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tis... | office notes, tympanoplasty surgery, traumatic perforation, external meatus, wax, external, perforation, eardrum, meatus, tympanoplasty, earNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and ... |
2,458 | Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter. | Office Notes | Normal ROS Template - 3 | HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm... | office notes, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling, |
2,459 | Negative for any nausea, vomiting, fevers, chills, or weight loss. | Office Notes | Normal ROS Template - 4 | GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobi... | office notes, review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting, |
2,460 | Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. | Office Notes | Normal ROS Template - 5 | REVIEW OF SYSTEMS,GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: Negative rash, negative jaundice.,HEMATOPOIETIC: Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: Negative ... | office notes, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness |
2,461 | The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints. | Office Notes | 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 ... | office notes, 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 accu... |
2,462 | There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. | Office Notes | Normal ROS Template - 1 | REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. The... | office notes, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for referenc... |
2,463 | Most commonly used phrases in physical exam. | Office Notes | Normal Physical Exam Template - 7 | EYES: , The conjunctivae are clear. The lids are normal appearing without evidence of chalazion or hordeolum. The pupils are round and reactive. The irides are without any obvious lesions noted. Funduscopic examination shows sharp disk margins. There are no exudates or hemorrhages noted. The vessels are normal ap... | office notes, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination, |
2,464 | Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress. | Office Notes | Normal Physical Exam Template - 5 | GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetric... | office notes, respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical, |
2,465 | Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. | Office Notes | Normal ROS Template - 2 | GENERAL:, Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, neg... | office notes, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness, |
2,466 | An example normal physical exam | Office Notes | Normal Physical Exam Template - 1 | GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformit... | office notes, vital signs, equal, round, reactive, normal physical exam, physical exam, |
2,467 | Normal physical exam template. Normocephalic. Negative lesions, negative masses. | Office Notes | Normal Physical Exam Template - 4 | GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructi... | |
2,468 | Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact. | Office Notes | Normal Physical Exam Template - 2 | GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:, The... | null |
2,469 | Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss. | Office Notes | Normal ROS Template | REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:, Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and den... | office notes, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss, |
2,470 | Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill. | Office Notes | Normal Physical Exam Template - 6 | VITAL SIGNS:, Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are... | office notes, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, |
2,471 | An example of a physical exam | Office Notes | Normal Physical Exam Template | GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.,EYES: ,Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.,EAR, N... | office notes, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam, |
2,472 | Normal physical exam template. Well developed, well nourished, in no acute distress. | Office Notes | Normal Physical Exam Template - 3 | PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:, ***,SKIN: ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:, The sclerae were anicteric and conjunctivae were pink and moist. Extraocular movements were intact and pupils were equ... | |
2,473 | An example/template for a routine normal male ROS. | Office Notes | Normal Male ROS Template - 1 | REVIEW OF SYSTEMS:,CONSTITUTIONAL: Patient denies fevers, chills, sweats and weight changes.,EYES: Patient denies any visual symptoms.,EARS, NOSE, AND THROAT: No difficulties with hearing. No symptoms of rhinitis or sore throat.,CARDIOVASCULAR: Patient denies chest pains, palpitations, orthopnea and paroxysmal noc... | office notes, review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary |
2,474 | Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress. | Office Notes | 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... | office notes, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant, |
2,475 | Template for History and Physical for a newborn. | Office Notes | 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 |
2,476 | An example/template for a routine normal male physical exam. | Office Notes | Normal Male Exam Template - 3 | PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae ... | null |
2,477 | An example/template for a routine normal male physical exam. | Office Notes | Normal Male Exam Template - 1 | MALE PHYSICAL EXAMINATION,HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate.,NECK: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no... | office notes, male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx |
2,478 | An example/template for a routine normal male physical exam. | Office Notes | Normal Male Exam Template - 2 | MALE PHYSICAL EXAMINATION,Eye: Eyelids normal color, no edema. Conjunctivae with no erythema, foreign body, or lacerations. Sclerae normal white color, no jaundice. Cornea clear without lesions. Pupils equally responsive to light. Iris normal color, no lesions. Anterior chamber clear. Lacrimal ducts normal. Fu... | office notes, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape, |
2,479 | Sample/template for a normal male multisystem exam. | Office Notes | Normal Male Exam Template | MULTISYSTEM EXAM,CONSTITUTIONAL: ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: ,The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: ... | office notes, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue, |
2,480 | An example/template for a routine normal male physical exam. | Office Notes | Normal Male Exam Template - 4 | VITAL SIGNS:, Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:, Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. No p... | office notes, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue, |
2,481 | Normal female review of systems template. Negative for fever, weight change, fatigue, or aching. | Office Notes | Normal Female ROS Template | CONSTITUTIONAL:, Normal; negative for fever, weight change, fatigue, or aching.,HEENT:, Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. Ears normal; Negative for hearing or balance problems. Nose normal; Negative for runny nose, sinus problems, or nosebleeds... | office notes, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, |
2,482 | Sample normal ear, nose, mouth, and throat exam. | Office Notes | Normal ENT Exam - 1 | EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympani... | office notes, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling, |
2,483 | Nephrology office visit for followup of CKD. | Office Notes | Nephrology Office Visit - 2 | HISTORY OF PRESENT ILLNESS:, This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney. His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable. He denies any chest pain or tightness in his ch... | null |
2,484 | An example/template for a routine normal female physical exam. | Office Notes | Normal Female Exam Template - 1 | PHYSICAL EXAMINATION,GENERAL: ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae a... | null |
2,485 | Sample normal ear, nose, mouth, and throat exam. | Office Notes | Normal ENT Exam | EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks an... | office notes, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample ... |
2,486 | Normal child physical exam template. | Office Notes | 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... | office notes, child physical examination, physical, genitalia, child, |
2,487 | Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure. | Office Notes | Myoclonic Epilepsy | DIAGNOSES:,1. Juvenile myoclonic epilepsy.,2. Recent generalized tonic-clonic seizure.,MEDICATIONS:,1. Lamictal 250 mg b.i.d.,2. Depo-Provera.,INTERIM HISTORY: , The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She ha... | office notes, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure |
2,488 | Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing | Office Notes | Hip Pain | CHIEF COMPLAINT:, | office notes, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn, |
2,489 | An example/template for a routine normal female physical exam. | Office Notes | Normal Female Exam Template - 2 | VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:, Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. E... | office notes, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue, |
2,490 | Sample/template for a normal female multisystem exam | Office Notes | Normal Female Exam Template | MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: , The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: ,... | |
2,491 | Nephrology office visit for followup of microscopic hematuria. | Office Notes | Nephrology Office Visit - 1 | HISTORY OF PRESENT ILLNESS: ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria. History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. The patient has no new joint pains; however, she d... | office notes, nephrology, creatinine, cystoscopy, glomerular, high power fields, hyperlipidemia, hypertension, microscopic hematuria, proteinuria, pyelogram, red cell, retrograde, sonogram, urinalysis, red cells, hematuria |
2,492 | Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. | Office Notes | Gen Med Office Note - 1 | HISTORY OF PRESENT ILLNESS:, The patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fr... | office notes, congestive cardiac failure, ejection fraction, atrial fibrillation, congestive cardiac, cardiac failure, office, lisinopril, metoprolol, hepatitis, fibrillation, hyperthyroidism, atrial, cardiac, congestive, |
2,493 | Patient complains of constipation. Has not had BM for two days. | Office Notes | Constipation - 1 | Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General: Pleasant, brighter.,Vital signs: 117/78, 12, 56.,Abdomen: Soft, nontender. Bowel sounds normal.,ASSESSMENT AND PLAN:,1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a w... | office notes, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema, |
2,494 | The patient with continued problems with her headaches. | Office Notes | Headache - Office Visit | She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred ... | office notes, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran |
2,495 | Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain | Office Notes | Chest Pain - Office Note | DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPIT... | office notes, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test |
2,496 | Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged. | Office Notes | Induction of Vaginal Delivery | DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she ... | office notes, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars |
2,497 | Cardiology office visit sample note. | Office Notes | Cardiology Office Visit - 2 | HISTORY OF PRESENT ILLNESS:, This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension. Patient has severe backache secondary to disc herniation. Patient has seen an orthopedic doctor and is scheduled for surgery. Patient also came to my office for s... | |
2,498 | Vaginal Hysterectomy. A weighted speculum was placed in the posterior vaginal vault. The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips. | Obstetrics / Gynecology | Vaginal Hysterectomy | null | obstetrics / gynecology, omentum, massachusetts, vaginal hysterectomy, vaginal vault, vaginal mucosa, vicryl suture, hysterectomy, ligaments, speculum, ligated, vaginal, sutureNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHel... |
2,499 | Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. | Office Notes | Abnormal Stress Test | HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitro... | office notes, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress |
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