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2,600 | Total vaginal hysterectomy. Microinvasive carcinoma of the cervix. | Obstetrics / Gynecology | Hysterectomy - Discharge Summary - 2 | ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation. ... | obstetrics / gynecology, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix, |
2,601 | Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy. | Obstetrics / Gynecology | Hemivulvectomy | PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a h... | obstetrics / gynecology, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning, |
2,602 | Vaginal discharge with a foul odor. | Obstetrics / Gynecology | Gardnerella Bacterial Vaginosis | CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration. The patient states that she has also had frequency of urination. The p... | null |
2,603 | Laparoscopic supracervical hysterectomy. Menorrhagia and dysmenorrhea. | Obstetrics / Gynecology | Hysterectomy - Laparoscopic Supracervical | PREOPERATIVE DIAGNOSES:, Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simpl... | obstetrics / gynecology, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar |
2,604 | The patient underwent a total vaginal hysterectomy. | Obstetrics / Gynecology | Hysterectomy - Discharge Summary | ADMISSION DIAGNOSES:,1. Menorrhagia.,2. Uterus enlargement.,3. Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and in... | obstetrics / gynecology, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy, |
2,605 | First Pap smear, complaining of irregular periods. - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods. | Obstetrics / Gynecology | First Pap smear. | CHIEF COMPLAINT:, The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:, The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. She notes that her periods are out of weck. She says that she has cramping and pa... | null |
2,606 | Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids. | Obstetrics / Gynecology | Hysterectomy - Discharge Summary - 1 | ADMISSION DIAGNOSES:,1. Menometrorrhagia.,2. Dysmenorrhea.,3. Small uterine fibroids.,DISCHARGE DIAGNOSES:,1. Menorrhagia.,2. Dysmenorrhea.,3. Small uterine fibroids.,OPERATION PERFORMED: ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL: ,The patient is a 42 year-old white female, gravida 3, para 2, with... | obstetrics / gynecology, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids, |
2,607 | Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer). | Obstetrics / Gynecology | Full-Field Digital Mammogram (FFDM) - 2 | EXAM: , Screening full-field digital mammogram.,HISTORY:, Screening examination of a 58-year-old female who currently denies complaints. Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy. The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: ... | obstetrics / gynecology, digital mammography, full-field digital mammogram, ffdm, second look version, field digital mammogram, digital mammogram, breast cancer, mammographic, icad, microcalcifications, mammogram, screening, digital, mammography, breast |
2,608 | Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings) | Obstetrics / Gynecology | Full-Field Digital Mammogram (FFDM) - 1 | EXAM: , Digital screening mammogram.,HISTORY:, 51-year-old female presents for screening mammography. Patient denies personal history of breast cancer. Breast cancer was reported in her maternal aunt.,TECHNIQUE:, Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. Comp... | obstetrics / gynecology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography |
2,609 | External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation. | Obstetrics / Gynecology | External Cephalic Version | PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:, A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,The pa... | obstetrics / gynecology, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine, |
2,610 | Fractional dilatation and curettage | Obstetrics / Gynecology | Dilatation & Curettage - D&C | PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED: ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding. An office endometrial b... | obstetrics / gynecology, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage |
2,611 | Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. | Obstetrics / Gynecology | Endometrial Cancer Followup | CHIEF COMPLAINT:,1. Stage IIIC endometrial cancer.,2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with t... | obstetrics / gynecology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease, |
2,612 | A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss. | Obstetrics / Gynecology | Ectopic Pregnancy - Discharge Summary | HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possibl... | obstetrics / gynecology, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic, |
2,613 | Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. | Obstetrics / Gynecology | Dilation & Evacuation | PREOPERATIVE DIAGNOSIS:, 12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS: ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding f... | obstetrics / gynecology, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina, |
2,614 | Emergency cesarean section. | Obstetrics / Gynecology | Emergency C-section. | PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA: ,... | obstetrics / gynecology, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine, |
2,615 | The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. | Obstetrics / Gynecology | Fetal Anatomical Survey | PAST MEDICAL HISTORY: ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY H... | obstetrics / gynecology, vaginal delivery, transducer, transabdominal ultrasound, placenta, amniotic fluid, fetal anatomical survey, preterm delivery, twin gestation, gestation, infant, fetal, anatomical, delivery, ultrasound, |
2,616 | Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst. | Obstetrics / Gynecology | Exploratory Laparotomy - 2 | PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ... | obstetrics / gynecology, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis, |
2,617 | Diagnostic Mammogram and ultrasound of the breast. | Obstetrics / Gynecology | Diagnostic Mammogram | EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast. Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. ... | obstetrics / gynecology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable |
2,618 | She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation. | Obstetrics / Gynecology | Delivery Note - 9 | DELIVERY NOTE:, This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive fern... | obstetrics / gynecology, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: 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 re... |
2,619 | Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started. | Obstetrics / Gynecology | Delivery Note - 8 | DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital. The patient was admitted to labor and delivery on Tuesday, December 22, 2... | obstetrics / gynecology, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: 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 ... |
2,620 | Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix. | Obstetrics / Gynecology | Diagnostic Laparoscopy - 1 | PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:, Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:, None.,CULTURES:, Intra-abdominally are done.,HISTORY: ,The patient is a 31-year-old Afr... | obstetrics / gynecology, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic, |
2,621 | The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy. | Obstetrics / Gynecology | Diagnostic Laparoscopy | TITLE OF OPERATION:, Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotra... | obstetrics / gynecology, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy, |
2,622 | The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting. | Obstetrics / Gynecology | Delivery Note - 7 | DELIVERY NOTE:, The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009. The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008. She was found to be positive for Nitrazine pull and fern. At tha... | obstetrics / gynecology, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify ac... |
2,623 | Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes. | Obstetrics / Gynecology | Delivery Note - 6 | DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09. The patient is a patient of Dr. X's. Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She also has a history of tobacco abuse with asthma. She was admitted here and labor was ... | obstetrics / gynecology, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: 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.The... |
2,624 | Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. | Obstetrics / Gynecology | Delivery Note - 5 | DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear flui... | obstetrics / gynecology, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: 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.T... |
2,625 | She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown. | Obstetrics / Gynecology | Delivery Note - 4 | DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated. Membranes ruptured this morning by me with some meconium. An IUPC was placed. Some Pitocin was started because the contractions were very... | obstetrics / gynecology, iupc, meconium, pitocin, epidural, rectum, sphincter, labor, perineum, pushed, deliveryNOTE,: 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.Th... |
2,626 | Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. | Obstetrics / Gynecology | Delivery Note - 3 | DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal deli... | obstetrics / gynecology, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality ... |
2,627 | Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior. | Obstetrics / Gynecology | Delivery Note | HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030... | obstetrics / gynecology, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal |
2,628 | Pitocin was started quickly to allow for delivery as quickly as possible. Baby was delivered with a single maternal pushing effort with retraction by the forceps. | Obstetrics / Gynecology | Delivery Note - 2 | Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck. These were variable decelerations occurring late in the contracti... | obstetrics / gynecology, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by variou... |
2,629 | The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum. | Obstetrics / Gynecology | Delivery Note - 10 | DELIVERY NOTE: ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor. The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact ... | obstetrics / gynecology, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does ... |
2,630 | Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions. | Obstetrics / Gynecology | D&C & Laparoscopy - 2 | PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Lapa... | null |
2,631 | Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy. | Obstetrics / Gynecology | D&C & Tubal Pregnancy Removal | PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Right ruptured tubal pregnancy.,2. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA: ... | obstetrics / gynecology, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy, |
2,632 | Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum. | Obstetrics / Gynecology | D&C, Laparoscopy, & Salpingectomy | PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,3. Hemoperitoneum.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Right salpingectomy.,4. Lysis of adhesions.,5. Evacuation of hemoperitoneum.,ANESTHESIA: , G... | obstetrics / gynecology, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube, |
2,633 | Spontaneous controlled sterile vaginal delivery performed without episiotomy. | Obstetrics / Gynecology | Delivery Note - 1 | The patient presented in the early morning hours of February 12, 2007, with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilatio... | obstetrics / gynecology, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: Thesetranscribed medica... |
2,634 | Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis. | Obstetrics / Gynecology | D&C & Laparoscopy - 1 | PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,5. Possible adenomyosis.,6. Lef... | null |
2,635 | Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye. | Obstetrics / Gynecology | D&C & Laparoscopy | PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Pelvic pain.,3. Infertility.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Infertility.,3. Pelvic pain.,4. Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy.,3. Injection of indigo carmine dye.,GROSS FIN... | obstetrics / gynecology, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus, |
2,636 | Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy. | Obstetrics / Gynecology | D&C & Hysteroscopy | PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Hypermenorrhea.,3. Secondary anemia.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm. Th... | obstetrics / gynecology, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus |
2,637 | Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus. | Obstetrics / Gynecology | D&C - Discharge Summary | ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,OPERATIONS PERFORMED:,1. Hysteroscopy.,2. Dilatation and curettage (D&C).,3.... | obstetrics / gynecology, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid, |
2,638 | D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6. Grade 1+ rectocele. | Obstetrics / Gynecology | D&C & Hysteroscopy Followup | PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spot... | obstetrics / gynecology, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus |
2,639 | A female with unknown gestational age who presents to the ED after a suicide attempt. | Obstetrics / Gynecology | Consult/ER Report - OB/GYN | The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period. She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus. She states that upon removal of a tampon, she saw a ta... | null |
2,640 | Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast. | Obstetrics / Gynecology | CT Abdomen & Pelvis - OB-GYN | EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDING... | obstetrics / gynecology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen |
2,641 | Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele. | Obstetrics / Gynecology | Culdoplasty & Vaginal Hysterectomy | PREOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,PROCEDURE PERFORMED:,1. Laparoscopic a... | obstetrics / gynecology, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, ... |
2,642 | Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp. | Obstetrics / Gynecology | D&C & Hysteroscopy - 1 | PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical ... | obstetrics / gynecology, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery, |
2,643 | An 18-year-old white female who presents for complete physical, Pap, and breast exam. | Obstetrics / Gynecology | Complete Physical - Female | SUBJECTIVE:, This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college. She denies any problems at this time. Her last Pap smear was 06/25/2003 and was normal. She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.... | null |
2,644 | Cervical cone biopsy, dilatation & curettage | Obstetrics / Gynecology | Cone Biopsy | PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:, Cervical cone biopsy, dilatation & curettage.,SPECIMENS: ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a ... | obstetrics / gynecology, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy, |
2,645 | Colpocleisis and rectocele repair. | Obstetrics / Gynecology | Colpocleisis | PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:, Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us... | obstetrics / gynecology, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection, |
2,646 | Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization. | Obstetrics / Gynecology | Cesarean Section & BTL | PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANES... | obstetrics / gynecology, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine, |
2,647 | Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section. | Obstetrics / Gynecology | Cholestasis Of Pregnancy | FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On ... | obstetrics / gynecology, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis |
2,648 | Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. | Obstetrics / Gynecology | Breast Mass Excision - 2 | PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:, Breast mass, left.,PROCEDURE:, Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Pre... | obstetrics / gynecology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen, |
2,649 | Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA. | Obstetrics / Gynecology | Breast Radiation Therapy Followup | DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiaz... | obstetrics / gynecology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast, |
2,650 | Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. | Obstetrics / Gynecology | Cesarean Section | null | obstetrics / gynecology, peritoneum, cesarean section, abdominal incision, subcutaneous tissue, bladder flap, incision, cesarean, fascia, flap, abdominalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify ... |
2,651 | Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography. | Obstetrics / Gynecology | Breast Calcifications - Preop Consult | REASON FOR HOSPITALIZATION: ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distrib... | null |
2,652 | Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. | Obstetrics / Gynecology | Breast Mass Excision - 1 | PREOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,PROCEDURE PERFORMED: ,Excision of left breast mass and revision of scar.,ANESTHESIA: ,Local with sedation.,SPECIMEN: , Scar with left breast ... | obstetrics / gynecology, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable, |
2,653 | Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions. | Obstetrics / Gynecology | BTL & Salpingectomy | PREOPERATIVE DIAGNOSES:,1. Pregnancy at 38 weeks and three days.,2. Previous cesarean section x2.,3. Refusing trial of labor.,4. Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1. Pregnancy at 38 weeks and three days.,2. Previous cesarean section x2.,3. Refusing trial of labor.,4. Multiparity, se... | null |
2,654 | Ultrasound BPP - Advanced maternal age and hypertension. | Obstetrics / Gynecology | Biophysical Profile - 1 | HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of de... | obstetrics / gynecology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal, |
2,655 | Bilateral Mammogram, (abnormal) additional views requested | Obstetrics / Gynecology | Bilateral Mammogram | EXAM:, Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study... | obstetrics / gynecology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography, |
2,656 | A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain. | Neurosurgery | Wound Closure & Debridement - Hydrocephalus | TITLE OF OPERATION:, A complex closure and debridement of wound.,INDICATION FOR SURGERY:, The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; howev... | neurosurgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, surgery, draining, fistula, wound, |
2,657 | Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir. | Neurosurgery | VP Shunt Placement | TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with... | neurosurgery, ommaya reservoir, frontal, strata valve, intraventricular hemorrhage, vp shunt, ventriculoperitoneal, hydrocephalus, |
2,658 | Endoscopic third ventriculostomy. | Neurosurgery | Ventriculostomy | PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:, Aqueductal stenosis.,TITLE OF PROCEDURE: ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:, Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION: ,ChloraPrep.,COMPLICATI... | neurosurgery, aqueductal stenosis, ventriculostomy, triventricular hydrocephalus, neuropen, endoscopic third ventriculostomy, endotracheal tube anesthesia, burr hole port, aqueductal, |
2,659 | Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast. | Obstetrics / Gynecology | Breast Ultrasound & Biopsy | EXAM: ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patien... | obstetrics / gynecology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound, |
2,660 | Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions. | Obstetrics / Gynecology | Abdominosacrocolpopexy | PREOPERATIVE DIAGNOSES:,1. Vault prolapse.,2. Enterocele.,PREOPERATIVE DIAGNOSES:,1. Vault prolapse.,2. Enterocele.,OPERATIONS:,1. Abdominosacrocolpopexy.,2. Enterocele repair.,3. Cystoscopy.,4. Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,SPECIMEN: , None.,B... | obstetrics / gynecology, enterocele repair, cystoscopy, lysis of adhesions, enterocele, ethibond stitches, indigo carmine, vault prolapse, sacrocolpopexy, peritoneum, abdominosacrocolpopexy, |
2,661 | Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure. | Neurosurgery | Ventriculostomy Placement | PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PRO... | neurosurgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular |
2,662 | Burr hole and insertion of external ventricular drain catheter. | Neurosurgery | Ventricular Drain Catheter Insertion | PREOPERATIVE DIAGNOSES:, Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:, Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedat... | neurosurgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter, |
2,663 | BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes. | Obstetrics / Gynecology | Biophysical Profile | CLINICAL HISTORY:, Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation. The placenta was posterior in position. There was normal fetal breathing movement, gross body ... | obstetrics / gynecology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE |
2,664 | Desires permanent sterilization. Laparoscopic bilateral tubal occlusion with Hulka clips. | Obstetrics / Gynecology | Bilateral Tubal Occlusion - Laparoscopic | PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS: ,None.,FINDINGS: , On bimanual exam, the ... | obstetrics / gynecology, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips, |
2,665 | Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally. | Neurosurgery | Vein Stripping | PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 inc... | neurosurgery, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous, |
2,666 | Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration. | Obstetrics / Gynecology | Breast Mass Excision | PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:, Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:, Excision of right breast mass.,PROCEDURE:, With the patient in the supine position, the right breast was prepped and draped ... | obstetrics / gynecology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass, |
2,667 | 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. | Neurosurgery | 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... | neurosurgery, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve |
2,668 | Bilateral temporal artery biopsy. Rule out temporal arteritis. | Neurosurgery | Temporal Artery Biopsy | PREOPERATIVE DIAGNOSIS:, Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS: ,Rule out temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsy.,ANESTHESIA:, Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:, I was consulted by Dr. X for this patient with bilateral temporal headaches to rule o... | neurosurgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis |
2,669 | Headaches, question of temporal arteritis. Bilateral temporal artery biopsies. | Neurosurgery | Temporal Artery Biopsy - 1 | PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right tempo... | neurosurgery, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis, |
2,670 | Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty. | Neurosurgery | Suboccipital Craniectomy | TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma. The patient is having surgery for resection. There was significant cerebellar peduncle compression. The tumor was ... | neurosurgery, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor |
2,671 | Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3. | Neurosurgery | Skull Base Reconstruction | PREOPERATIVE DIAGNOSIS:, Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right select... | neurosurgery, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath |
2,672 | Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new. | Neurosurgery | Shunt Revision - 2 | PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS: ,None.,COMPLICATIONS:, None.,ANESTHESIA:, General.,SKIN PREPARATIO... | neurosurgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular, |
2,673 | 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. | Neurosurgery | 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... | neurosurgery, 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, |
2,674 | 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. | Neurosurgery | 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... | neurosurgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated, |
2,675 | Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma. | Neurosurgery | Pterional Craniotomy | PREOPERATIVE DIAGNOSIS: ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneur... | neurosurgery, hemorrhage, arteriovenous malformation, aneurysm, pterional craniotomy, bone flap, bipolar coagulation, arteriovenous, pterional, malformation, hematoma, intracerebral, |
2,676 | Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus. | Neurosurgery | Pituitary Adenomectomy | PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:, Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tis... | |
2,677 | Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end. | Neurosurgery | Shunt Revision - 3 | PREOPERATIVE DIAGNOSIS:, Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:, Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal. He is almost... | neurosurgery, bactiseal, bactiseal catheter, codman bactiseal, blocked ventriculoperitoneal shunt, ventriculoperitoneal shunt revision, ventricular catheter, shunt revision, ventriculoperitoneal shunt, catheter, ventriculoperitoneal, ventricular, shunt |
2,678 | Endoscopic proximal shunt revision. | Neurosurgery | Shunt Revision - 1 | PREOPERATIVE DIAGNOSIS: , Shunt malfunction. The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:, Shunt malfunction. The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: ,... | neurosurgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter, |
2,679 | Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion. | Neurosurgery | 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... | neurosurgery, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical, |
2,680 | Bilateral endoscopic proximal shunt revision and a distal shunt revision. | Neurosurgery | Shunt Revision | TITLE OF OPERATION:, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:, Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:, Coaptation of ventricles against proximal end ... | neurosurgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal |
2,681 | Placement of Scott cannula, right lateral ventricle | Neurosurgery | Scott Cannula | PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the... | neurosurgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: 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 sampl... |
2,682 | Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. | Neurosurgery | Ommaya reservoir | TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. Recommendation was for an Ommaya reservoir. Risks and benefits have been explained. They agreed to pr... | neurosurgery, caprosyn, leukemic meningitis, ommaya reservoir, leukemia, meningeal, intrathecal, chemotherapy, leukemic, meningitis, ommaya, |
2,683 | Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. | Neurosurgery | Pituitary Tumor Resection | TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI dem... | neurosurgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary, |
2,684 | Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts. | Neurosurgery | Phenol Neurolysis & Botulinum Toxin Injection - 3 | PROCEDURE CODES: 64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA: MAC.,COMPLICATIONS: None.,DESCRIPTION OF TECHNIQUE: Informed consent was obtained from th... | neurosurgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, pheno... |
2,685 | Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection. | Neurosurgery | Neuroplasty | PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibr... | neurosurgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural, |
2,686 | Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles. | Neurosurgery | Phenol Neurolysis & Botulinum Toxin Injection - 2 | PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 34... | neurosurgery, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectorali... |
2,687 | Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation. | Neurosurgery | Lumbar Re-exploration | PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthes... | neurosurgery, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware, |
2,688 | Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors. | Neurosurgery | Phenol Neurolysis & Botulinum Toxin Injection - 1 | PROCEDURES PERFORMED:, Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadripare... | neurosurgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculo... |
2,689 | Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the... | Neurosurgery | Nerve & Tendon Repair - Finger | PREOPERATIVE DIAGNOSIS:, Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2. 25% laceration to the ... | neurosurgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar, |
2,690 | Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. | Neurosurgery | Lumbar Puncture | REASON FOR VISIT: ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:, The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left... | null |
2,691 | Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw in... | Neurosurgery | Laminotomy, Facetectomy & Foraminotomy | PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and righ... | neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle |
2,692 | Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.
| Neurosurgery | Lumbar Laminotomy & Discectomy | PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Le... | neurosurgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated, |
2,693 | L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy. | Neurosurgery | Laminotomy & Microdissection | PREOPERATIVE DIAGNOSES: ,1. Fractured and retained lumbar subarachnoid spinal catheter.,2. Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES: ,1. L1 laminotomy.,2. Microdissection.,3. Retrieval of foreign body (retained lumbar spinal catheter).,4. Attempted insertion of new external lumbar drai... | neurosurgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter, |
2,694 | Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. | Neurosurgery | Lumbar Puncture - 2 | PROCEDURE PERFORMED:, Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. Alternatives were explained. They agreed to proceed with the lumbar puncture. Permit was signed and is on the chart. The indicat... | neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf |
2,695 | Lumbar puncture with moderate sedation. | Neurosurgery | Lumbar Puncture - 1 | PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. ... | neurosurgery, moderate sedation, lumbar puncture, needle, lumbar, |
2,696 | Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula. | Neurosurgery | Lumbar Laminectomy | PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:, Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1. Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2. Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDIC... | neurosurgery, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina, |
2,697 | Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain. | Neurosurgery | Lumbar Laminectomy & Discectomy | PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1. Injection for myelogram.,2. Microscopic-assisted lumbar laminec... | neurosurgery, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram |
2,698 | Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. Posterior lumbar interbody arthrodesis utilizing cage... | Neurosurgery | Laminectomy & Foraminotomy Revision | PREOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable ... | null |
2,699 | Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. | Neurosurgery | Hemicraniectomy | TITLE OF OPERATION:, Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: , The patient is a patient well known to my service. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. I took her t... | neurosurgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE |
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