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3,100 | Occupational medicine consult with questions-answers and records review. | IME-QME-Work Comp etc. | Occupational Medicine Consult | ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:, AC joint arthrosis right aggravation.,DISALLOWED CONDITION: , | null |
3,101 | Chiropractic IME with old files review. Detailed Thoracic Spine Examination. | IME-QME-Work Comp etc. | 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 |
3,102 | Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. | Hospice - Palliative Care | Lung Cancer & MI - Hospice Cosult | REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her... | null |
3,103 | Hospice visit for 77-year-old gentleman with advanced colon cancer. | Hospice - Palliative Care | Hospice Visit - Colon Cancer | HISTORY OF PRESENT ILLNESS:, History as provided primarily by the patient's daughter, as well as the referring physician revealed an approximately two-year history of colon cancer initially diagnosed when the patient presented with a swelling in his groin. Approximately one month ago, he presented with abdominal pain... | hospice - palliative care, hospice, cat scan results, hospice nurse, pet scan, abdominal pain, admitted to hospital, cirrhosis, colon cancer, colon obstruction, esophageal varices, longstanding, moisture barrier, referring physician, health, colon, cancer, |
3,104 | Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation. | IME-QME-Work Comp etc. | Back Injury IME | PAST MEDICAL CONDITION:, None.,ALLERGIES:, None.,CURRENT MEDICATION:, Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:, The patient is a 52-year-old male who is here for independent medical evaluation. The ... | ime-qme-work comp etc., rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology, |
3,105 | Initial visit for a 95-year-old gentleman with a Hospice diagnosis of CHF. | Hospice - Palliative Care | Hospice Visit - CHF | HISTORY:, This is an initial visit for this 95-year-old gentleman with a Hospice diagnosis of CHF. He was referred to us by Dr. ABC, who reveals a long history of cardiomyopathy and a recent decrease in his ejection fraction to approximately 20-25%. The patient was seen in the office approximately three days ago wit... | hospice - palliative care, hospice, chf, dnr, dnr was placed, hospice team, air entry, appetite, bronchitis, cardiomyopathy, clinical diagnosis, ejection fraction, functional decline, hospitalization, hospitalized, initial visit, plan of care, somnolent, weight loss, |
3,106 | Chiropractic IME with answers to questions from Insurance Company. | IME-QME-Work Comp etc. | 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 |
3,107 | First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. | IME-QME-Work Comp etc. | Burn - Consult | CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents wi... | ime-qme-work comp etc., burn, workers' compensation industrial injury, workers' compensation, degree |
3,108 | Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs. | Hospice - Palliative Care | Hospice Visit - CA of Cervix | HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum, lung, which was diagnosed approximately two years ago. There is a nodule in her lung, which was treated by excision in February of 2007 on the right side. She had spread to her kidney. She had... | hospice - palliative care, hospice, carcinoma of the cervix, code status, length of the encounter, mmtp program, normal affect, shortness of breath, bladder, decline, exchange of information, hospice care, irritable obstruction, lung, nephrectomy, nephrostomy, performance status, poor appetite, prognosis is likely to b... |
3,109 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | Hospice - Palliative Care | Hospice Visit - AIDS | HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. His viral load in July of 2007 was 254,000 and CD4 count was 7. He was recently admitted for debility and possible pneumonia. He was started on antiretro... | hospice - palliative care, hospice, aids, cd4 count, code status, dnr, kaposi's sarcoma, length of the encounter, cryptococcal infection, exchange of information, health care proxy, home hospice, home hospice care, hospice care, hospitalization, viral load, bowel, infection |
3,110 | Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis. | Hematology - Oncology | Thyroid Mass Consult | REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS: ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now b... | null |
3,111 | Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support. | Hospice - Palliative Care | Care Conference With Family | REASON FOR FOLLOWUP:, Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient ... | hospice - palliative care, full code status, terminal wean, comfort care, cpr, advanced cardiac life support, care conference, family, bedsideNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy an... |
3,112 | Essential thrombocytosis. He underwent a bone marrow biopsy, which showed essential thrombocytosis. His CBC has been very stable. | Hematology - Oncology | Thrombocytosis Followup | CHIEF COMPLAINT:, Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis. He was first diagnosed when he first saw a hematologist on 07/09/07. At that time, his platelet count was 1,240,000. He was initially started... | null |
3,113 | Consultation for evaluation of thrombocytopenia. | Hematology - Oncology | Thrombocytopenia - Consult | REASON FOR CONSULTATION:, Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:, Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. He... | null |
3,114 | Patient with immune thrombocytopenia | Hematology - Oncology | Thrombocytopenia - SOAP Note | SUBJECTIVE: , I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematolo... | hematology - oncology, platelets, platelet count, thrombocytopenia, prednisone, |
3,115 | True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. | Hematology - Oncology | True Cut Needle Biopsy - Breast | PREOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS: ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam,... | hematology - oncology, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast, |
3,116 | Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer. | Hematology - Oncology | Tongue Lesion Biopsy | PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED: ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration i... | hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy, |
3,117 | The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. | Hematology - Oncology | Uterine Papillary Serous Carcinoma | HISTORY OF PRESENT ILLNESS:, The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right uppe... | hematology - oncology, chemotherapy, uterine papillary serous carcinoma, oophorectomy, carboplatin, taxol, abdominal, uterine, papillary, carcinoma, |
3,118 | Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. | Hematology - Oncology | T-Cell Lymphoma Consult | CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess... | hematology - oncology, t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck, |
3,119 | Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx. | Hematology - Oncology | Symes Amputation - Hallux | PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputa... | hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux |
3,120 | Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy. | Hematology - Oncology | Posttransplant Lymphoproliferative Disorder | CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1. Posttransplant lymphoproliferative disorder.,2. Chronic renal insufficiency.,3. Squamous cell carcinoma of the skin.,4. Anemia secondary to chronic renal insufficiency and chemotherapy.,5. Hypertension.,HISTORY OF PRESENT ILL... | hematology - oncology, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative, |
3,121 | A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain. | Hematology - Oncology | Sickle Cell Anemia - ER Visit | HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a room mate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies an... | null |
3,122 | Prostate Brachytherapy - Prostate I-125 Implantation | Hematology - Oncology | Prostate Brachytherapy | PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound ... | hematology - oncology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: 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 ... |
3,123 | Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure. | Hematology - Oncology | Resection of Tumor of Scalp | PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined are... | hematology - oncology, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor, |
3,124 | Invasive carcinoma of left breast. Left modified radical mastectomy. | Hematology - Oncology | Radical Mastectomy | PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast... | hematology - oncology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy |
3,125 | Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. | Hematology - Oncology | Sepsis - Consult | REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet ... | null |
3,126 | Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound. | Hematology - Oncology | Parathyroid Adenoma Excision | PREOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:, Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:, This 80-year-old woman has had some mi... | hematology - oncology, parathyroid adenoma, superior parathyroid adenoma, excision, sestamibi parathyroid scan, sestamibi parathyroid, parathyroid scan, sternohyoid muscles, superior parathyroid, parathyroid, sestamibi, platysma, adenoma, ultrasound, sternohyoid, thyroid, muscles |
3,127 | Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. | Hematology - Oncology | Polycythemia Vera Followup | DIAGNOSIS:, Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006... | hematology - oncology, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis, |
3,128 | Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site. | Hematology - Oncology | Nuclear Medicine Lymphatic Scan | EXAM:, Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the origina... | hematology - oncology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast, |
3,129 | Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. | Hematology - Oncology | Polycythemia Rubra Vera | CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levoth... | hematology - oncology, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia, |
3,130 | Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst. | Hematology - Oncology | Pilonidal Cyst Excision | PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:, Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operat... | hematology - oncology, hemostasis, excision, pilonidal cyst, cyst, abscess, infected, |
3,131 | The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection. | Hematology - Oncology | Neuroblastoma - Consult | REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and... | null |
3,132 | Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. | Hematology - Oncology | Non-Hodgkin lymphoma Followup | CHIEF COMPLAINT:, Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin... | null |
3,133 | New diagnosis of non-small cell lung cancer stage IV metastatic disease. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable. | Hematology - Oncology | Non-Small Cell Lung Cancer - Consult | REASON FOR CONSULTATION:, New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease. We are consulted at this time to discuss furthe... | null |
3,134 | Left neck dissection. Metastatic papillary cancer, left neck. The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection. | Hematology - Oncology | Neck Dissection | PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA: ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, remo... | hematology - oncology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer |
3,135 | A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. | Hematology - Oncology | Metastatic Ovarian Cancer - Consult | REASON FOR CONSULTATION:, Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has r... | null |
3,136 | Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast. | Hematology - Oncology | Needle Localized Excision - Breast Neoplasm | PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED: ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS: ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detect... | hematology - oncology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast |
3,137 | MGUS. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS. | Hematology - Oncology | MGUS Followup | CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:, This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.... | null |
3,138 | Discharge summary of a patient presenting with a large mass aborted through the cervix. | Hematology - Oncology | Mullerian Adenosarcoma | PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma. ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST: Clear. There is no heart murmur.,ABDOMEN: Nontender.,PELVIC: There is a large mass in the vagina. ,HOSPITAL COURSE: , The patien... | hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma |
3,139 | Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy. | Hematology - Oncology | Mesothelioma - Port-A-Cath Insertion | PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:, None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who un... | hematology - oncology, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma, |
3,140 | Rhabdomyosarcoma of the left orbit. Left subclavian vein MediPort placement. Needs chemotherapy. | Hematology - Oncology | MediPort Placement | PREOPERATIVE DIAGNOSIS:, Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:, Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left ... | hematology - oncology, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport, |
3,141 | Right nodular malignant mesothelioma. | Hematology - Oncology | Mesothelioma - Thoracotomy & Lobectomy | PREOPERATIVE DIAGNOSIS:, Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1. Right thoracotomy.,2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , ... | hematology - oncology, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy, |
3,142 | Marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. she had a mammogram and ultrasound, which confirmed the right breast mass. | Hematology - Oncology | Marginal Zone Lymphoma | CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram an... | null |
3,143 | Malignant mass of the left neck, squamous cell carcinoma. Left neck mass biopsy and selective surgical neck dissection, left. | Hematology - Oncology | Neck Mass Biopsy | PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:, Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1. Left neck mass biopsy.,2. Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:, After obtaining an informed, the patient was taken to the operat... | hematology - oncology, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein, |
3,144 | Right pleural effusion and suspected malignant mesothelioma. | Hematology - Oncology | Mesothelioma - Pleural Biopsy | PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:, General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural ef... | hematology - oncology, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma, |
3,145 | Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter. | Hematology - Oncology | Lymphoblastic Leukemia - Consult | CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient w... | null |
3,146 | Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. | Hematology - Oncology | Lung Cancer & MI - Hospice Cosult | REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her... | null |
3,147 | A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant. | Hematology - Oncology | Mantle Cell Lymphoma | PRINCIPAL DIAGNOSES:,1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. ... | null |
3,148 | Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax. | Hematology - Oncology | Lung Cancer Followup | CHIEF COMPLAINT:,1. Extensive stage small cell lung cancer.,2. Chemotherapy with carboplatin and etoposide.,3. Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment wit... | hematology - oncology, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer, |
3,149 | Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia. | Hematology - Oncology | Leiomyosarcoma | ADMITTING DIAGNOSES:,1. Leiomyosarcoma.,2. History of pulmonary embolism.,3. History of subdural hematoma.,4. Pancytopenia.,5. History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2. CTA, chest PE study showing no evidenc... | hematology - oncology, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary, |
3,150 | Left axillary lymph node excisional biopsy. Left axillary adenopathy. | Hematology - Oncology | Lymph Node Excisional Biopsy | PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF... | hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy |
3,151 | Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis. | Hematology - Oncology | Lymphoma - Consult | HISTORY OF PRESENT ILLNESS:, The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago. The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction. The patient again went into complete remission. The patient has been doing ... | null |
3,152 | Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. | Hematology - Oncology | Mantle Cell Lymphoma - Consult | CHIEF COMPLAINT:, Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006. On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. ... | null |
3,153 | Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis. | Hematology - Oncology | Iron deficiency anemia | CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage he... | hematology - oncology, trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco, |
3,154 | A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy. | Hematology - Oncology | Intraperitoneal Mesothelioma | REASON FOR ADMISSION:, Intraperitoneal chemotherapy.,HISTORY: , A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma. The patient has received prior intravenous chemotherapy. Due to some increasing renal insufficiency and difficulties with hydration... | hematology - oncology, chemo, taxol, intraperitoneal mesothelioma, peritoneal mesothelioma, intravenous chemotherapy, adrenal gland, hemorrhagic cyst, peritoneal, intraperitoneal, hemorrhagic, mesothelioma, chemotherapy, |
3,155 | Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. | Hematology - Oncology | Intensity-Modulated Radiation Therapy | INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropria... | hematology - oncology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: 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 ... |
3,156 | Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery. | Hematology - Oncology | Glioma - Consult | REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982. She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery. She did well for the... | null |
3,157 | Hyperfractionation. This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. | Hematology - Oncology | Hyperfractionation | HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this ... | hematology - oncology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality... |
3,158 | Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. | Hematology - Oncology | Head & Neck Cancer Consult | REASON FOR CONSULTATION:, Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. He was also noted to have ... | null |
3,159 | Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation. | Hematology - Oncology | Hematology Consult | REASON FOR CONSULTATION:, Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS: ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or sur... | null |
3,160 | Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. | Hematology - Oncology | Intensity-Modulated Radiation Therapy Simulation | INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-base... | hematology - oncology, target volume, intensity modulated radiation therapy, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical t... |
3,161 | Asked to see the patient in regards to a brain tumor. She was initially diagnosed with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. | Hematology - Oncology | Glioblastoma Multiforme - Consult | REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our... | null |
3,162 | Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. | Hematology - Oncology | Hematology Consult - 1 | HISTORY OF PRESENT ILLNESS:, The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis. We corrected her hematocrit last year with intravenous (IV) iron. Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis. Her course has been very... | null |
3,163 | HDR Brachytherapy | Hematology - Oncology | HDR Brachytherapy | HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. Simulation films were obtained, documenting its positioning. The 3-dimensional treatment planning process was accomplished utilizing the CT derived data. A treatment plan was selected u... | hematology - oncology, geiger-muller, treatment planning, hdr brachytherapy, intracavitary, applicator, brachytherapyNOTE,: 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 repor... |
3,164 | 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. | Hematology - Oncology | 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... | hematology - oncology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease, |
3,165 | Re-excision of squamous cell carcinoma site, right hand. | Hematology - Oncology | Excision of Squamous Cell Carcinoma | PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:, Local with monitored anesthesia care.,INDICAT... | hematology - oncology, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma |
3,166 | Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid. | Hematology - Oncology | Eyelid Squamous Cell Carcinoma Excision | PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS: ,None.... | hematology - oncology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis, |
3,167 | Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis. | Hematology - Oncology | Discharge Summary - Mesothelioma - 1 | PRINCIPAL DIAGNOSIS:, Mesothelioma.,SECONDARY DIAGNOSES:, Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2. On August 20, 2007, thoracentes... | null |
3,168 | A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma. | Hematology - Oncology | Discharge Summary - Mesothelioma | PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1. Flexible bronchoscopy.,2. Mediastinoscopy.,3. Right thoracotomy.,4. Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1. Radiation Oncology.,2. Pulmonary Medicin... | hematology - oncology, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology, |
3,169 | Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. | Hematology - Oncology | Disseminated Intravascular Coagulation | DIAGNOSES:,1. Disseminated intravascular coagulation.,2. Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and ... | hematology - oncology, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated, |
3,170 | Concomitant chemoradiotherapy for curative intent patients. | Hematology - Oncology | Concomitant Chemoradiotherapy | CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate a... | hematology - oncology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: 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 med... |
3,171 | Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved. | Hematology - Oncology | Craniopharyngioma - Postop | REASON FOR VISIT:, Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:, Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, u... | hematology - oncology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma, |
3,172 | Conformal simulation with coplanar beams. This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. | Hematology - Oncology | Conformal Simulation | CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing... | hematology - oncology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: 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 medica... |
3,173 | Patient presents with complaint of lump in the upper outer quadrant of the right breast | Hematology - Oncology | Consult - Breast Cancer | CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. ... | null |
3,174 | The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma. | Hematology - Oncology | Consult - Breast Cancer - 1 | CHIEF COMPLAINT: , Left breast cancer.,HISTORY:, The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferom... | |
3,175 | Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. | Hematology - Oncology | Colon Polyps - Genetic Counseling | REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were fo... | hematology - oncology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps, |
3,176 | Routine colorectal cancer screening. He occasionally gets some loose stools. | Hematology - Oncology | Colon Cancer Screening | HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems... | hematology - oncology, colon cancer screening, loose stools, colorectal, colonoscopy, |
3,177 | Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA. | Hematology - Oncology | 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... | hematology - oncology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast, |
3,178 | 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. | Hematology - Oncology | 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... | hematology - oncology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen, |
3,179 | Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. | Hematology - Oncology | Breast Cancer Followup - 1 | CHIEF COMPLAINT:, Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS: ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right bre... | null |
3,180 | T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation. | Hematology - Oncology | Cancer of the nasopharynx | DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history o... | hematology - oncology, radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx, |
3,181 | Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration. | Hematology - Oncology | 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 ... | hematology - oncology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass, |
3,182 | Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements. | Hematology - Oncology | Colon Cancer Consult | REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:, The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms migh... | null |
3,183 | Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. | Hematology - Oncology | Cholangiocarcinoma Consult | REASON FOR CONSULTATION:, Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder finding... | |
3,184 | 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. | Hematology - Oncology | 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 ... | hematology - oncology, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable, |
3,185 | A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. | Hematology - Oncology | Breast Cancer Followup | CHIEF COMPLAINT:,1. Metastatic breast cancer.,2. Enrolled is clinical trial C40502.,3. Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She ... | hematology - oncology, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer, |
3,186 | Excisional biopsy of right cervical lymph node. | Hematology - Oncology | Biopsy - Cervical Lymph Node | PREOPERATIVE DIAGNOSIS: , Cervical lymphadenopathy.,POSTOPERATIVE DIAGNOSIS:, Cervical lymphadenopathy.,PROCEDURE: , Excisional biopsy of right cervical lymph node.,ANESTHESIA: , General endotracheal anesthesia.,SPECIMEN: , Right cervical lymph node.,EBL: , 10 cc.,COMPLICATIONS: , None.,FINDINGS:, Enlarged level 2 ly... | hematology - oncology, lymphadenopathy, excisional biopsy, fna, mastisol, penrose drain, cervical, cervical lymph node, endotracheal anesthesia, lymph node, sternocleidomastoid, cervical lymph, lymph, anesthesia, |
3,187 | Excision of nasal tip basal carcinoma, previous positive biopsy. | Hematology - Oncology | BCCa Excision - Nasal Tip | PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma. Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins c... | hematology - oncology, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal |
3,188 | The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. | Hematology - Oncology | Brain Tumor - Consult | REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was tr... | hematology - oncology, spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent |
3,189 | Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap. | Hematology - Oncology | BCCa Excision - Canthus | PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm di... | hematology - oncology, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma, |
3,190 | Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy. | Hematology - Oncology | Biopsy - Axillary Lymph Node | PREOPERATIVE DIAGNOSES:,1. Right axillary adenopathy.,2. Thrombocytopenia.,3. Hepatosplenomegaly.,POSTOPERATIVE DIAGNOSES:,1. Right axillary adenopathy.,2. Thrombocytopenia.,3. Hepatosplenomegaly.,PROCEDURE PERFORMED: ,Right axillary lymph node biopsy.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,DI... | hematology - oncology, hepatosplenomegaly, thrombocytopenia, axillary adenopathy, axillary lymph node biopsy, axillary lymph node, lymph node biopsy, lymph node, lymph, node, axillary, adenopathy, hemostasis, suture, biopsy, |
3,191 | Discharge summary of a patient with a BRCA-2 mutation. | Hematology - Oncology | BRCA-2 mutation | DISCHARGE DIAGNOSES:, BRCA-2 mutation. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION: ,The chest was clear. The abdomen was nontender. Pelvic examination shows no mas... | hematology - oncology, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer, |
3,192 | Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft. | Hematology - Oncology | BCCa Excision - Lower Lid | PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:, Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large p... | hematology - oncology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival, |
3,193 | Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma. | Hematology - Oncology | 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... | hematology - oncology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma |
3,194 | Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. | Hematology - Oncology | Anemia & Leukemia Followup | CHIEF COMPLAINT:,1. Chronic lymphocytic leukemia (CLL).,2. Autoimmune hemolytic anemia.,3. Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnos... | hematology - oncology, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune, |
3,195 | Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease. | Hematology - Oncology | Axillary Dissection & Mass Excision | PREOPERATIVE DIAGNOSIS:, Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS: ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1. Left axillary dissection with incision and drainage of left axillary mass.,2. Right axillary mass excision and ... | hematology - oncology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary, |
3,196 | Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants | Hematology - Oncology | BCCa Excision - Cheek | PREOPERATIVE DIAGNOSES,1. Basal cell carcinoma, right cheek.,2. Basal cell carcinoma, left cheek.,3. Bilateral ruptured silicone gel implants.,4. Bilateral Baker grade IV capsular contracture.,5. Breast ptosis.,POSTOPERATIVE DIAGNOSES,1. Basal cell carcinoma, right cheek.,2. Basal cell carcinoma, left cheek.,3. ... | null |
3,197 | Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone. | Hematology - Oncology | Aplastic Anemia Followup | CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospita... | null |
3,198 | Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. | Hematology - Oncology | Anemia - Consult | DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, st... | null |
3,199 | Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal. | Hematology - Oncology | Adrenalectomy & Umbilical Hernia Repair | PREOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA: ,General.,CLINICAL NOTE: , This is a 52-year-old inmate ... | hematology - oncology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia, |
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