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3,000 | Right radical nephrectomy and assisted laparoscopic approach. | Nephrology | Nephrectomy - Radical | PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient underwent general anesthesia with endotracheal intubation. An orogastric was placed and a Foley c... | nephrology, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical, |
3,001 | Laparoscopic right partial nephrectomy due to right renal mass. | Nephrology | Nephrectomy - Partial (Laparoscopic ) | PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:, 250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:, General endotra... | nephrology, renal mass, foley catheter, gerota fascia, jp drain, kocher maneuver, laparoscopic, ligasure device, satinsky clamp, toldt, bulldogs, nephrectomy, renal parenchyma, resection, urethra, vicryl sutures, partial nephrectomy, gonadal vein, renal hilum, satinsky, renal, kidney, hilum, foley, endotracheal, |
3,002 | Left partial nephrectomy due to left renal mass. | Nephrology | Nephrectomy - Partial | PREOPERATIVE DIAGNOSIS:, Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:, Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from th... | nephrology, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl, |
3,003 | Status post cadaveric kidney transplant with stable function. | Nephrology | Kidney Transplant - Followup | REASON FOR VISIT:, Kidney transplant.,HISTORY OF PRESENT ILLNESS: , The patient is a 52-year-old gentleman with ESRD secondary to hypertension, status post kidney transplant in February 2006. He had to back down on his WelChol because of increased backache. He actually increased his Pravachol and is tolerating this ... | nephrology, esrd secondary to hypertension, status post cadaveric kidney transplant, transplant with stable function, cadaveric kidney transplant, secondary to hypertension, stable function, cadaveric kidney, kidney transplant, esrd, hyperlipidemia, edema, cadaveric, welchol, orthopnea, kidney, transplant, |
3,004 | Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy. | Nephrology | Laparoscopic Cryoablation | PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:, Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 100 Ml.,FLUIDS: , Crystalloid.,The patient wa... | nephrology, hand-assisted laparoscopic cryoablation, laparoscopic, cryoablation, bilateral renal mass, fibrin glue, laparoscopic cryoablation, renal insufficiency, renal lesions, renal biopsy, renal mass, insufficiency, renal, freezing/thawing, lesions |
3,005 | Left laparoscopic hand-assisted nephrectomy. | Nephrology | Nephrectomy | PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS: ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:, General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:, The pa... | nephrology, laparoscopic, nephrectomy, laparoscopic hand assisted nephrectomy, triple lumen catheter, lumen catheter, running fashion, renal mass, renal bleed, dissection, hemostasis, kidney, renal |
3,006 | Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty. Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis. | Nephrology | Laparoscopic Pyeloplasty | PREOPERATIVE DIAGNOSIS: ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1. Right ureteropelvic junction obstruction.,2. Severe intraabdominal adhesions.,3. Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Attempted laparoscopic pyeloplasty.,3. Open laparo... | nephrology, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions, |
3,007 | Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated. | Nephrology | Indwelling Catheter Insertion | PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS: ,Chronic renal failure.,PROCEDURE PERFORMED:, Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male present... | nephrology, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis, |
3,008 | Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula. | Nephrology | Hemodialysis Fistula Construction | PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF ... | nephrology, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial |
3,009 | Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter. | Nephrology | Internal Jugular Vein Catheter Insertion | PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.... | nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein |
3,010 | Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula. | Nephrology | Fogarty Thrombectomy | PREOPERATIVE DIAGNOSES:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex ... | nephrology, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene |
3,011 | Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula. | Nephrology | Fistulogram & Angioplasty | PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, ... | null |
3,012 | Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. | Nephrology | Leaking Nephrostomy Tube | CHIEF COMPLAINT: ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. The leaking began this a.m. The patient denies any pain, does not have fever and has no other problems or... | nephrology, nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes, |
3,013 | This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection. | Nephrology | ESRD - Discharge Summary | ADMISSION DIAGNOSIS:, End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:, Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis si... | null |
3,014 | Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain. | Nephrology | End Stage Renal Disease - Consult | REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status ... | null |
3,015 | Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy. | Nephrology | Discharge Summary - Nephrology | ADMITTING DIAGNOSES:, Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:, Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1. Chronic obstructive pulmonary disease.,2. Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HIS... | nephrology, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge, |
3,016 | Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea. | Nephrology | Hematuria - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on ... | null |
3,017 | The patient is being discharged for continued hemodialysis and rehab. | Nephrology | Discharge Summary - Hemodialysis | DISCHARGE DIAGNOSES:,1. End-stage renal disease, on hemodialysis.,2. History of T9 vertebral fracture.,3. Diskitis.,4. Thrombocytopenia.,5. Congestive heart failure with ejection fraction of approximately 30%.,6. Diabetes, type 2.,7. Protein malnourishment.,8. History of anemia.,HISTORY AND HOSPITAL COURSE: , T... | nephrology, end-stage renal disease, thrombocytopenia, anemia, hospitalization, hemodialysis and rehab, hemodialysis |
3,018 | Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection. | Nephrology | Discharge Summary - Urology & Nephrology | ADMITTING DIAGNOSES:, Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureterosc... | null |
3,019 | Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria. | Nephrology | Cystourethroscopy & Retrograde Pyelogram - 1 | PREOPERATIVE DIAGNOSES:,1. Right renal mass.,2. Hematuria.,POSTOPERATIVE DIAGNOSES:,1. Right renal mass.,2. Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Right retrograde pyelogram.,3. Right ureteral pyeloscopy.,4. Right renal biopsy.,5. Right double-J 4.5 x 26 mm ure... | nephrology, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogr... |
3,020 | Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma. | Nephrology | Cystourethroscopy & Retrograde Pyelogram | PREOPERATIVE DIAGNOSES:,1. Recurrent bladder tumor.,2. History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:, | nephrology, recurrent bladder tumor, bladder carcinoma, bilateral retrograde pyelogram, transurethral resection of bladder tumor, lateral wall bladder tumor, transurethral resection, retrograde pyelogram, tumor, bladder, cystourethroscopy, pyelogram, |
3,021 | Common Excretory Urogram - IVP template | Nephrology | Excretory Urogram - IVP | There is normal and symmetrical filling of the caliceal system. Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally. The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying... | nephrology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality o... |
3,022 | Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder. | Nephrology | Cystopyelogram - 1 | PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS: ,Gross hematuria.,OPERATIONS: ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS: ,Significant amount of bladder clots measuring about 150... | nephrology, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots, |
3,023 | Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy. | Nephrology | Cystoscopy, Ureteropyelogram, & Ureteral Barbotage | PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.... | nephrology, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine, |
3,024 | Right lower pole renal stone and possibly infected stent. Cysto stent removal. | Nephrology | Cysto Stent Removal | PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on va... | nephrology, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto, |
3,025 | Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached. | Nephrology | Cystopyelogram | PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient... | nephrology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent, |
3,026 | Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. | Nephrology | CT Abdomen & Pelvis - 9 | CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:, Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, adrenal glands, and kidneys are u... | nephrology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue, |
3,027 | Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300. | Nephrology | CT Abdomen & Pelvis - 8 | CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:, Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100... | nephrology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen |
3,028 | Noncontrast CT abdomen and pelvis per renal stone protocol. | Nephrology | CT KUB | EXAM: ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:, Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis, ureteral dilatation. There are calcifi... | nephrology, pericolonic inflammatory process, phleboliths, renal stone protocol, ct kub, ct abdomen, ureteral dilatation, free fluid, renal stone, noncontrast, kub, adenopathy, abdomen, ct, renal, stone, obstruction, pelvis |
3,029 | CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam. | Nephrology | CT-Guided Biopsy - Kidney | REASON FOR EXAM: This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE: The procedure risks and possible complications including, but not limited to severe hemor... | nephrology, embolization, ct localization, gelfoam pledgets, ct guided needle placement, ct guided biopsy, needle placement, renal mass, ct guided, inferior pole, ct, biopsy, hematoma, kidney, mass, |
3,030 | Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent. | Nephrology | Cysto & Double-J Stent Insersion | PREOPERATIVE DIAGNOSIS:, Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:, General via endotrache... | nephrology, residual stone, percutaneous, cobra catheters, amplatz, double j stent, pollack catheter, cysto, catheter, nephrolithotomy, stent, french |
3,031 | Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained. | Nephrology | CT Abdomen & Pelvis - 7 | REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lu... | nephrology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast |
3,032 | Noncontrast CT abdomen and pelvis per renal stone protocol. | Nephrology | CT Stone Protocol | EXAM: , CT stone protocol.,REASON FOR EXAM:, History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally. These are unchanged. There is no... | nephrology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast, |
3,033 | CT abdomen and pelvis without contrast, stone protocol, reconstruction. | Nephrology | CT Abdomen & Pelvis - 4 | EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatatio... | nephrology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast, |
3,034 | Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. | Nephrology | CT Head, Facial Bones, Cervical Spine - 1 | CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, o... | nephrology, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones, |
3,035 | Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. | Nephrology | CT Abdomen & Pelvis - 6 | REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the... | nephrology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct |
3,036 | CT of the abdomen and pelvis without contrast. | Nephrology | CT Abdomen & Pelvis - 3 | EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:, Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the s... | nephrology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen, |
3,037 | CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan. | Nephrology | CT Scan of Abdomen & Pelvis with Contrast | EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition, oral ReadiCAT was given. Reformatted sagit... | nephrology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis, |
3,038 | CT abdomen without contrast and pelvis without contrast, reconstruction. | Nephrology | CT Abdomen & Pelvis - 5 | EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is norma... | nephrology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast, |
3,039 | Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast. | Nephrology | CT Abdomen & Pelvis - 11 | EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen... | nephrology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen, |
3,040 | CT scan of the abdomen and pelvis without and with intravenous contrast. | Nephrology | CT Abdomen & Pelvis - 2 | EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. O... | nephrology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen, |
3,041 | CT Abdomen & Pelvis W&WO Contrast | Nephrology | CT Abdomen & Pelvis | EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison i... | nephrology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen, |
3,042 | Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast. | Nephrology | CT Abdomen & Pelvis - 10 | CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable. Within the ... | nephrology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen, |
3,043 | Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia. | Nephrology | Chronic Kidney Disease Followup - 1 | PROBLEMS LIST:,1. Type 1 diabetes mellitus, insulin pump requiring.,2. Chronic kidney disease, stage III.,3. Sweet syndrome.,4. Hypertension.,5. Dyslipidemia.,6. Osteoporosis.,7. Anemia.,8. A 25-hydroxy-vitamin D deficiency.,9. Peripheral neuropathy manifested by insensate feet.,10. Hypothyroidism.,11. Diabe... | null |
3,044 | CT Abdomen and Pelvis with contrast | Nephrology | CT Abdomen & Pelvis - 1 | EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bas... | nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct |
3,045 | Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia. | Nephrology | Chronic Kidney Disease Followup | HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease. His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him. I have been trying to get him educated abou... | nephrology, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney |
3,046 | Marked right hydronephrosis without hydruria. | Nephrology | Consult - Hydronephrosis | CHIEF COMPLAINT:, Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and a... | nephrology, hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer, |
3,047 | Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever. | Nephrology | Clogged AV Shunt - Consult | REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint. The patient complains of fatigue, nausea, vomiting and fever. The patient states that the shunt was placed in February, although acco... | null |
3,048 | Followup on chronic kidney disease. | Nephrology | Chronic Kidney Disease - Followup | REASON FOR VISIT:, Followup on chronic kidney disease.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old gentleman with stage III chronic kidney disease who on his last visit with me presented with classic anginal symptoms. He was admitted to hospital and found to have an acute myocardial infarction. He had... | null |
3,049 | This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors. | Nephrology | Chronic Kidney Disease - Consult | HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments. He was last seen in this clinic on 05/29/2007 by Dr. X. This is the first time that I have met the patie... | null |
3,050 | Left forearm arteriovenous fistula between cephalic vein and radial artery. | Nephrology | AV Fistula - 5 | PREOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection... | nephrology, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic |
3,051 | Creation of autologous right brachiobasilic arteriovenous fistula - first stage. | Nephrology | AV Fistula - 4 | PREOPERATIVE DIAGNOSES,1. End-stage renal disease.,2. Left subclavian vein occlusion.,3. Status post chronic tracheostomy.,4. Status post coronary artery bypass grafting.,5. Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease.,2. Left subclavian vein occlusion.,3. Status post chro... | nephrology, end-stage renal disease, left subclavian vein occlusion, arteriovenous fistula, artery bypass grafting, autologous, basilic vein, brachial artery, brachiobasilic, clamped, fistula, sclerotic, subclavian vein, subclavian vein stenosis, tracheostomy, brachiobasilic arteriovenous fistula, subclavian vein occlu... |
3,052 | Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism. | Nephrology | Azotemia Consult | REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath. He also started having some abdominal pain; however, he continued about his regular ... | nephrology, urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary, |
3,053 | Right basilic vein transposition. End-stage renal disease with need for a long-term hemodialysis access. Excellent flow through fistula following the procedure. | Nephrology | Basilic Vein Transposition | PREOPERATIVE DIAGNOSIS:, End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICAT... | nephrology, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic, |
3,054 | Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD. | Nephrology | Acute Kidney Failure | REASON FOR VISIT: , Acute kidney failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old Korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage III CKD with a creatinine of 1.8 in May 2006 corresponding with the GFR of 40-41 mL/min. The patient had blood work done at D... | null |
3,055 | Creation of AV fistula, left wrist in the anatomic snuffbox. | Nephrology | AV Fistula - 3 | TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an A... | nephrology, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula |
3,056 | Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula. | Nephrology | AV Fistula - 1 | PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesth... | nephrology, end-stage renal disease, prolene suture, venogram, antecubital fossa, arteriovenous, arteriovenous fistula, brachiocephalic arteriovenous fistula, cephalic vein, fistula, prepped and draped, brachiocephalic, cephalic, vein |
3,057 | He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. | Letters | Pediatric Urology Letter | XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE: XXXX, XXXX ,MR#: 0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic. I appreciate you speaking with me while he was in clinic. He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of ... | letters, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology, |
3,058 | Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation | Letters | Urology Letter | Sample Address,RE: Sample Patient,Wife's name: Sample Name,Dear Sample Doctor:,Mr. Sample Patient was seen on Month DD, YYYY, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan. He has remained azoospermic postoperatively. The operative note s... | letters, urology, letter, urology letter, azoospermic, cryopreservation, specimen harvest, sperm harvesting, vasectomy, vasectomy reversal, fresh specimen, reversal, sperm, |
3,059 | Diagnosis of benign rolandic epilepsy. | Letters | Rolandic Epilepsy | City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z. His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy. To review, his birth was unremarkable. He is a second child born to a G3, P1 to 2 female. H... | letters, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram, |
3,060 | A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine. | Letters | Wilson's Disease - Letter | Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future. He is a pleasant gentleman with a history of Wilson's disease. It has been treated with penicillamine. He was diagnosed with this at age 14. He was on his way to South Carolina for a trip when h... | letters, atrial enlargement, wilson's disease, penicillamine, |
3,061 | Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. | Letters | Suspected Seizure Activity | XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. He is requesting to come off the Dilantin a... | letters, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: 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 me... |
3,062 | Reflex sympathetic dystrophy of both lower extremities. | Letters | Reflex Sympathetic Dystrophy - Letter | Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008. As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisti... | letters, rsd, reflex sympathetic dystrophy, orthopedic, oxygenationNOTE,: 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 ... |
3,063 | Creation of right brachiocephalic arteriovenous fistula. | Nephrology | AV Fistula - 2 | PREOPERATIVE DIAGNOSES,1. End-stage renal disease.,2. Diabetes.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease.,2. Diabetes.,OPERATIVE PROCEDURE,Creation of right brachiocephalic arteriovenous fistula.,INDICATIONS FOR THE PROCEDURE,This patient has end-stage renal disease. Although, the patient is right-handed... | nephrology, end-stage renal disease, prolene suture, brachial artery, brachiocephalic, brachiocephalic arteriovenous fistula, cephalic vein, fistula, general anesthetic, prepped and draped, proximally and distally, renal disease, av, cephalic, artery, vein |
3,064 | The patient is being referred for evaluation of diabetic retinopathy. | Letters | 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... | letters, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic, |
3,065 | Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms. | Letters | Ortho - Letter - 2 | XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ 07018,Re: | letters, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger, |
3,066 | Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up. | Letters | 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... | letters, optometry, letter, optometry letter, pdt therapy, distance correction, macular degeneration, reading glasses, vision therapy, complete refractive, macular, degeneration, |
3,067 | Patient being referred for evaluation of glaucoma. | Letters | 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... | letters, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, ophthalmology, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact, |
3,068 | 9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months. | Letters | Pediatric - Letter | Sample Address,RE: Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing, cough and shortness of breath over... | letters, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma, |
3,069 | The patient was referred for evaluation of cataracts bilaterally | Letters | 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... | letters, extraocular, applanations, slit lamp, visual field, ophthalmology, visual, guttata, surgery, cataracts, eye, |
3,070 | A 19-year-old right-handed male injured in a motor vehicle accident. | Letters | Ortho - Letter - 1 | XYZ, D.C.,Re: ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side. The... | letters, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho, |
3,071 | Patient referred for narrow angles and possible associated glaucoma. | Letters | 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... | letters, intraocular pressures, narrow angles, visual fields, angles, ophthalmology, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye, |
3,072 | Female with intermittent rectal bleeding, not associated with any weight loss. The patient is chronically constipated. | Letters | Gastroenterology - Letter | Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermitten... | null |
3,073 | Diagnosis of bulbar cerebral palsy and hypotonia. | Letters | Cerebral Palsy - Letter | Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she no... | letters, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: 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 tran... |
3,074 | Letter on evaluation regarding extraction of mandibular left second molar tooth #18. | Letters | Letter - Dentistry | XYZ, S.,RE: ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18. This previously root-canaled tooth, now failed, is scheduled for removal. As per your request, I agree that placem... | letters, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth |
3,075 | Follow up update on patient with left carotid angioplasty and stent placement. | Letters | Cardiology - Letter | Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that sh... | letters, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: 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 transc... |
3,076 | Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease. | Letters | Cardiovascular - Letter | Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation. This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity. He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intole... | letters, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atheroscler... |
3,077 | Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma. | Letters | Anaplastic Astrocytoma - Letter | XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to underg... | letters, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma |
3,078 | Chiropractic IME with answers to questions from Insurance Company. | Letters | Chiropractic IME - 1 | P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and th... | null |
3,079 | Chiropractic IME with old files review. Detailed Thoracic Spine Examination. | Letters | Chiropractic IME - 2 | DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is... | null |
3,080 | Letter to the patient to let him know about his abnormal cholesterol test results. | Letters | Abnormal Cholesterol Result - Letter | ABNORMAL CHOLESTEROL RESULT LETTER,Recently you had a cholesterol test done. The cholesterol levels were abnormal. These are usually associated with increased risk for stroke and heart attack. I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best ... | letters, letter, ldl, abnormal, cholesterol, cholesterol level, cholesterol test, heart attack, hypercholesterolemia, increased risk, lab results, stroke, total cholesterol, abnormal cholesterol result, abnormal cholesterol, cholesterol levels, levels, treatment, dietNOTE,: Thesetranscribed medical transcription sample... |
3,081 | Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura. | Lab Medicine - Pathology | Immunohistochemical Study | CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:, Tumor cells show... | lab medicine - pathology, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor, |
3,082 | Prostate adenocarcinoma and erectile dysfunction - Pathology report. | Lab Medicine - Pathology | Pathology - Prostate | SPECIMENS:,1. Pelvis-right pelvic obturator node.,2. Pelvis-left pelvic obturator node.,3. Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1. Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invas... | lab medicine - pathology, pelvic obturator node, erectile dysfunction, seminal vesicle, prostate, lymph node, specimen, section, adenocarcinoma of prostate, pelvic obturator, tumor, lymph, node, specimens, adenocarcinoma, |
3,083 | Specimen labeled "right ovarian cyst" is received fresh for frozen section. | Lab Medicine - Pathology | Pathology - Ovarian Cyst | GROSS DESCRIPTION: , Specimen labeled "right ovarian cyst" is received fresh for frozen section. It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid. Both surfaces of the wall are pink-tan, smooth and grossly unremarkable. No firm or thick areas or papilla... | lab medicine - pathology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: 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.Thes... |
3,084 | Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". | Lab Medicine - Pathology | Lung adenocarcinoma Path Report | CLINICAL HISTORY: ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:, Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.c... | lab medicine - pathology, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung, |
3,085 | Specimen labeled "sesamoid bone left foot". | Lab Medicine - Pathology | Pathology - Sesamoid Bone | GROSS DESCRIPTION: , Specimen labeled "sesamoid bone left foot" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is entirely submi... | lab medicine - pathology, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample rep... |
3,086 | The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. | Lab Medicine - Pathology | Lung Biopsy Pathology Report - 1 | GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated "l... | lab medicine - pathology, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy |
3,087 | Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury | IME-QME-Work Comp etc. | Worker's Compensation Injury | CHIEF COMPLAINT:, Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:, The patient is a 21-year-old Hispanic female. She comes in today with her boyfriend. The patient speaks English fairly well, but her primary language is Spanish. Her boyfriend does help to make sure that she understands what we are talkin... | null |
3,088 | Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose. | IME-QME-Work Comp etc. | Records Review - Orthopedic | Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work harden... | null |
3,089 | Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. | Lab Medicine - Pathology | Lung Biopsy Pathology Report | CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diamet... | lab medicine - pathology, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node |
3,090 | Qualified medical evaluation report of a patient with back pain. | IME-QME-Work Comp etc. | Qualified Medical Evaluation Report | HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right si... | null |
3,091 | Is it BNP or BMP? | Lab Medicine - Pathology | BNP v/s BMP | BNP, (brain natriuretic peptide or B-type natriuretic peptide) is a substance produced in the heart ventricles when there is excessive strain to the heart muscles. A blood test for this can be used as an effective parameter for detecting an acute event of congestive heart failure, where the heart is unable to pump su... | lab medicine - pathology, brain natriuretic peptide, b-type natriuretic peptide, basic metabolic panel, glucose, calcium, sodium, potassium, bicarbonate, chloride, bun, creatinine, natriuretic peptide, bmp, bnp, |
3,092 | Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger. | IME-QME-Work Comp etc. | Records Review - Epicondylitis | ALLOWED CONDITIONS:, Lateral epicondylitis, right elbow,EMPLOYER:, ABCD,REQUESTED ALLOWANCE:, Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars. He does state he was employe... | null |
3,093 | Occupational medicine consult with questions-answers and records review. | IME-QME-Work Comp etc. | Occupational Medicine Consult - 3 | ALLOWED CONDITIONS:, Sprain of left knee and leg.,CONTESTED CONDITION:, Left knee tear medial meniscus, left knee ACL tear.,EMPLOYER:, YYYY,REQUESTING PARTY:, XXXX,Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the l... | null |
3,094 | Right shoulder impingement syndrome, right suprascapular neuropathy. | IME-QME-Work Comp etc. | Impairment Rating | CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried ... | ime-qme-work comp etc., ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular, |
3,095 | Occupational medicine consult with questions-answers and records review. | IME-QME-Work Comp etc. | Occupational Medicine Consult - 2 | ALLOWED CONDITIONS:, 726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,CONTESTED CONDITIONS:, 354.2 right cubital tunnel syndrome.,EMPLOYER:, ABCD, ,I examined Xxxxx today for the allowed conditions and also the contested conditions listed above. I obtained her history from company medical rec... | null |
3,096 | Occupational medicine consult with questions-answers. | IME-QME-Work Comp etc. | Occupational Medicine Consult - 1 | ALLOWED CONDITIONS:, Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:, Osteoarthritis of the left knee.,EMPLOYER:, ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee. He is a 57-year-old assembly worker... | null |
3,097 | Work restrictions and disability evaluation | IME-QME-Work Comp etc. | Permanent & Stationary Report | PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper... | null |
3,098 | Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. | IME-QME-Work Comp etc. | Major Depressive Disorder - IME Consult | IDENTIFYING DATA: ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy le... | ime-qme-work comp etc., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric, |
3,099 | A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall. | IME-QME-Work Comp etc. | IME & Record Review - Orthopedic | INTRODUCTION: , The opinions expressed in this report are those of the physician. The opinions do not reflect the opinions of Evergreen Medical Panel, Inc. The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I). The claimant was also inform... | null |
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