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3,400 | A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. | General Medicine | Discharge Summary - 9 | DISCHARGE DIAGNOSIS:,1. Epigastric pain. Questionable gastritis, questionable underlying myocardial ischemia.,2. Congestive heart failure exacerbation.,3. Small pericardial effusion with no tamponade.,4. Hypothyroidism.,5. Questionable subacute infarct versus neoplasm in the pons.,6. History of coronary artery d... | null |
3,401 | Patient with complaints of shortness of breath and was found to have acute COPD exacerbation. | General Medicine | Discharge Summary - 2 | ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyro... | null |
3,402 | Patient with fever of unknown origin. | General Medicine | Discharge Summary - 7 | REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week. The patient has also been on high-dose prednisone for an urticarial rash. The patient was admitted because of persistent high fevers without ... | general medicine, fever of unknown origin, blood cultures, transbronchial biopsies, infection, cmv, admission, illness, interstitial, fever, serologies, chest, nondiagnostic, methotrexate |
3,403 | Patient with increased shortness of breath of one day duration. | General Medicine | Discharge Summary - 3 | DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF... | general medicine, chronic obstructive pulmonary disease, hypercapnic respiratory failure, atrial fibrillation, chronic atrial fibrillation, increased shortness of breath, shortness of breath, increased shortness, coumadin, atrial, |
3,404 | A white female with a history of fevers. | General Medicine | Discharge Summary - 8 | DISCHARGE DIAGNOSES:,1. Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007... | general medicine, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge |
3,405 | Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation. | General Medicine | Discharge Summary - Migraine | ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:, Migraine with aura.,SECONDARY DIAGNOSES:,1. Bipolar disorder.,2. Iron deficiency anemia.,3. Anxiety disorder.,4. History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1. CT of the head with and without contrast, which was ne... | null |
3,406 | The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection. | General Medicine | Discharge Summary - 19 | PRIMARY DISCHARGE DIAGNOSES:,1. Urinary tract infection.,2. Gastroenteritis with nausea and vomiting.,3. Upper gastrointestinal bleed likely secondary to gastritis.,4. Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1. Hypertension.,2. Gastroesophageal reflux disease.,3. Chronic atrial fibrillation... | null |
3,407 | The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out. | General Medicine | Discharge Summary - 18 | ADMISSION DIAGNOSES:,1. Atypical chest pain.,2. Nausea.,3. Vomiting.,4. Diabetes.,5. Hypokalemia.,6. Diarrhea.,7. Panic and depression.,8. Hypertension.,DISCHARGE DIAGNOSES:,1. Serotonin syndrome secondary to high doses of Prozac.,2. Atypical chest pain with myocardial infarction ruled out.,3. Diabetes melli... | null |
3,408 | Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome. | General Medicine | Discharge Summary - 13 | ADMITTING DIAGNOSES:,1. Bradycardia.,2. Dizziness.,3. Diabetes.,4. Hypertension.,5. Abdominal pain.,DISCHARGE DIAGNOSIS:, Sick sinus syndrome. The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patien... | null |
3,409 | The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved. | General Medicine | Discharge Summary - 17 | FINAL DIAGNOSIS/REASON FOR ADMISSION:,1. Acute right lobar pneumonia.,2. Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3. Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4. Elevated liver function tests, etiology undetermined.,5. The patient has a history of moderate-to... | general medicine, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures |
3,410 | Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever. | General Medicine | Discharge Summary - 16 | ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week... | general medicine, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis, |
3,411 | Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. | General Medicine | Discharge Summary - 15 | FINAL DIAGNOSES:,1. Gastroenteritis.,2. Autism.,DIET ON DISCHARGE:, Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESE... | general medicine, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall |
3,412 | Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis. | General Medicine | Discharge Summary - 11 | ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF... | general medicine, medifast, hyperglycemia, laparoscopic cholecystectomy, medifast diet, cholecystitis, cholelithiasis, diabetes mellitus, hypertension, morbid obesity, obstructive sleep apnea, sleep apnea, diabetes, |
3,413 | Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia. | General Medicine | Discharge Summary - 1 | DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/200... | null |
3,414 | The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. | General Medicine | Discharge Summary - 14 | HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained b... | general medicine, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission, |
3,415 | Patient today with ongoing issues with diabetic control. | General Medicine | Diabetes Mellitus - SOAP Note - 2 | SUBJECTIVE:, I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in ... | general medicine, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses, |
3,416 | Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis. | General Medicine | Cough & Abdominal Pain | CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient sta... | null |
3,417 | A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse. | General Medicine | Detox from Heroin | CHIEF COMPLAINT:, Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mos... | general medicine, phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse, |
3,418 | Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care. | General Medicine | Cut on Foot - ER Visit | CHIEF COMPLAINT:, Cut on foot.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has n... | general medicine, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body, |
3,419 | A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity. | General Medicine | Discharge Summary - 12 | CURRENT HISTORY:, A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI. She also has renal insufficiency and digitalis toxicity. She is admitted for further treatment.,Past medical history, social history, family history, physical examination c... | null |
3,420 | Patient with a past medical history of hypertension for 15 years. | General Medicine | Consult - Hypertension | HISTORY OF PRESENT ILLNESS:, The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension. According to the patient, s... | general medicine, hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, renal, |
3,421 | Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigast... | General Medicine | Consult - Sepsis | REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of b... | null |
3,422 | The patient needs refills on her Xanax | General Medicine | Consult - Smoking Cessation | CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:, The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cau... | general medicine, quit smoking, chantix, mesothelioma, smoking, xanax, refills |
3,423 | Followup diabetes mellitus, type 1. | General Medicine | Diabetes Mellitus - SOAP Note - 1 | CHIEF COMPLAINT: ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:, Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar du... | general medicine, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars |
3,424 | Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom exc... | General Medicine | Consult - Coronary Artery Disease | REASON FOR CONSULTATION:, Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subseq... | null |
3,425 | Nonhealing right ankle stasis ulcer. A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery. | General Medicine | Consult - Stasis Ulcer | REASON FOR THE CONSULT:, Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for... | null |
3,426 | The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema. | General Medicine | Consult - CHF & Lymphedema | HISTORY OF PRESENT ILLNESS:, The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema. He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung. This consultation was made for better control of his blood ... | null |
3,427 | Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. | General Medicine | COPD & Pneumonia - SOAP | SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, she does not use oxygen at her independent assisted... | general medicine, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd |
3,428 | A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. | General Medicine | Consult - Vomiting & Nausea | CHIEF COMPLAINT:, Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. She states she has it at least once a day. It can be any time, but can also be postprandial. She states she will vomit up some dark brown-to-green fluid.... | null |
3,429 | Patient was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. | General Medicine | Consult - Syncope | REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS: ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies ... | null |
3,430 | A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to... | General Medicine | Consult - Chest Pain - 1 | REASON FOR CONSULTATION:, Chest pain.,HISTORY OF PRESENT ILLNESS: , The patient is a 37-year-old gentleman admitted through emergency room. He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphore... | null |
3,431 | Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis. | General Medicine | Chronic Medical Conditions - Followup | REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:, The patient has been doing quite well since he was last seen. He comes in today with his daughter. He has had no symptoms of CAD or CHF. He had followup with Dr. X and she thought he was doing quite we... | general medicine, congestive heart failure, diabetes, hyperlipidemia, chronic renal insufficiency, arthritis, chronic medical conditions, heart, |
3,432 | A 2-month-old female with 1-week history of congestion and fever x2 days. | General Medicine | Congestion & Fever - 2-month-old | CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid b... | null |
3,433 | Patient with multiple problems, main one is chest pain at night. | General Medicine | Consult - Chest Pain | CHIEF COMPLAINT:, Multiple problems, main one is chest pain at night.,HISTORY OF PRESENT ILLNESS:, This is a 60-year-old female with multiple problems as numbered below:,1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and... | null |
3,434 | A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. | General Medicine | Congestion & Cough - 5-month-Old | CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough w... | null |
3,435 | Congestion, tactile temperature. | General Medicine | Congestion - 21-day-old | CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any p... | null |
3,436 | Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh. | General Medicine | Chronic Abscesses - Discharge Summary | DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft t... | general medicine, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics, |
3,437 | Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. | General Medicine | Chest Wall Lump - Consult | CHIEF COMPLAINT:, Lump in the chest wall.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he take... | null |
3,438 | The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea. | General Medicine | C. Diff Colitis Consult | REASON FOR CONSULT: ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18... | null |
3,439 | Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography. | General Medicine | Breast Calcifications - Preop Consult | REASON FOR HOSPITALIZATION: ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distrib... | null |
3,440 | Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. | General Medicine | Cellulitis - Discharge Summary | DISCHARGE DIAGNOSIS: ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1. Chronic pain.,2. Tobacco use.,3. History of hepatitis C.,REASON FOR ADMISSION:, The patient is a 52-year-old male who has had a very complex cou... | general medicine, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis, |
3,441 | First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. | General Medicine | 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... | general medicine, burn, workers' compensation industrial injury, workers' compensation, degree |
3,442 | Left buttock abscess, status post incision and drainage. Recommended some local wound care | General Medicine | Buttock Abscess | CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The... | general medicine, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess, |
3,443 | 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. | General Medicine | 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 ... | general medicine, 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 and quality... |
3,444 | Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia. | General Medicine | Atrial Fibrillation - SOAP | SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracin... | general medicine, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic, |
3,445 | A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina. | General Medicine | Chest Pain & Respiratory Insufficiency | We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have ni... | general medicine, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic |
3,446 | Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria. | General Medicine | Blood in Urine - ER Visit | CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS: ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient n... | null |
3,447 | Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure. | General Medicine | Asbestos Exposure - Hemoptysis | REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure. The patient also has a very extensive cardiac history that would be outlined below. He is being admitt... | null |
3,448 | Antibiotic management for a right foot ulcer and possible osteomyelitis. | General Medicine | Antibiotic Management Consult | REASON FOR CONSULTATION: , Antibiotic management for a right foot ulcer and possible osteomyelitis.,HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old Caucasian male with past medical history of diabetes mellitus. He was doing fairly well until last week while mowing the lawn, he injured his right foot. He pr... | null |
3,449 | Questionable need for antibiotic therapy for possible lower extremity cellulitis. | General Medicine | Antibiotic Therapy Consult | REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospita... | null |
3,450 | Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. | General Medicine | 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 |
3,451 | Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed. | General Medicine | Blood In Toilet | CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no ... | null |
3,452 | Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain. | General Medicine | Admission History & Physical - Nausea | CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped ... | general medicine, gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery, |
3,453 | Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids. | General Medicine | Annual Health Maintenance Exam | HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dys... | general medicine, tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign |
3,454 | Possible exposure to ant bait. She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation. | General Medicine | Ant Bait Exposure - ER Visit | CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not s... | general medicine, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms, |
3,455 | This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. | Gastroenterology | Wound Check - Status Post APR | HISTORY OF PRESENT ILLNESS:, Ms. Connor is a 50-year-old female who returns to clinic for a wound check. The patient underwent an APR secondary to refractory ulcerative colitis. Subsequently, she developed a wound infection, which has since healed. On our most recent visit to our clinic, she has her perineal stitch... | gastroenterology, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE |
3,456 | Upper endoscopy with foreign body removal (Penny in proximal esophagus). | Gastroenterology | Upper Endoscopy - Foreign Body Removal | PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediat... | gastroenterology, upper endoscopy, endoscopy, endoscopy suite, esophagus, foreign body, foreign body removal, esophageal foreign body, stomach, |
3,457 | Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology. | General Medicine | Air Under Diaphragm - Consult | REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be... | null |
3,458 | Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery. | Gastroenterology | Umbilical Hernia Repair - 1 | PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:, After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was ... | gastroenterology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical, |
3,459 | The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily. | General Medicine | Acute Cystitis & Diabetes Type II | HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies e... | null |
3,460 | Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets. | General Medicine | Accidental Celesta Ingestion - ER Visit | HISTORY OF PRESENT ILLNESS:, Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets. Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated. Th... | general medicine, accidental ingestion of celesta, celesta, tablets, ingestion, |
3,461 | The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. | General Medicine | Abdominal Pain - Consult | CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evalua... | null |
3,462 | Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill. | Gastroenterology | Viral Gastroenteritis | HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine." She states after vomiting, she felt "fine through the night," but woke with more nausea and v... | gastroenterology, nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill, |
3,463 | Upper endoscopy with removal of food impaction. | Gastroenterology | Upper Endoscopy | PROCEDURE:, Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years. She comes in this morning with complaints of inability to swallow anything including her saliva. This started almost a day earlier. She was eating lunch an... | gastroenterology, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus, |
3,464 | Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique. This lady has a bowel obstruction. She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. | Gastroenterology | Ttriple-Lumen Central Line | PREOPERATIVE DIAGNOSES,1. Bowel obstruction.,2. Central line fell off.,POSTOPERATIVE DIAGNOSES,1. Bowel obstruction.,2. Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.... | gastroenterology, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction |
3,465 | Ultrasound Abdomen - elevated liver function tests. | Gastroenterology | Ultrasound - Abdomen - 1 | EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of th... | gastroenterology, aorta, dilated common duct, mrcp, ercp, elevated liver function tests, pancreatic duct, distended bladder, ultrasound abdomen, cholecystectomy, ultrasound, abdomen, liver, dilatation, caliectasis, kidney, bladder, duct |
3,466 | Ultrasound abdomen, complete | Gastroenterology | Ultrasound - Abdomen | EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia. The patient has diffuse abdominal pain. There is a history of AIDS.,TECHNIQUE:, An ultrasound examination of the abdomen was performed.,FINDINGS:, Th... | gastroenterology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound |
3,467 | Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation. | Gastroenterology | Thoracotomy & Esophageal Exploration | PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube ... | gastroenterology, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, ... |
3,468 | Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia. | Gastroenterology | Umbilical Hernia Repair | PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL: ,The patient was prepped and draped in the sterile fashion. An infraumbilical ... | gastroenterology, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia, |
3,469 | Closure of gastrostomy placed due to feeding difficulties. | Gastroenterology | Surgical Closure of Gastrostomy | PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties. Since then, he has... | gastroenterology, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy |
3,470 | Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy | Gastroenterology | Stamm Gastrostomy Tube Placement | PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis ... | |
3,471 | She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline ... | Gastroenterology | SOAP - Cholecystitis | SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with ... | gastroenterology, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis |
3,472 | Pediatric Gastroenterology - Rectal Bleeding Consult. | Gastroenterology | Rectal Bleeding - 1-year-old | HISTORY OF PRESENT ILLNESS:, This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was ha... | null |
3,473 | A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation. | Gastroenterology | Status Post Liver Transplant | HISTORY OF PRESENT ILLNESS:, This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant. The patient did well after the liver transplant and the only problems started:,1. History of food allergies.,2. History of den... | null |
3,474 | History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction. | Gastroenterology | Small Bowel Obstruction | CHIEF COMPLAINT:, Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anythi... | null |
3,475 | A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. | Gastroenterology | Rectal Bleeding - Consult | REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physic... | null |
3,476 | Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding. | Gastroenterology | Sigmoidoscopy - 1 | PROCEDURE: , Sigmoidoscopy.,INDICATIONS:, Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:, A history and physical examination were performed. The procedure, indications, potential complication... | gastroenterology, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids, |
3,477 | Ultrasound-Guided Paracentesis for Ascites | Gastroenterology | Paracentesis - Ultrasound-Guided | EXAM:, Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS: ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained. Ultrasound demonstrates free fluid in the abdomen. The area of interest was localized with ultrasonography. The ... | gastroenterology, yueh catheter, aspiration of fluid, ultrasound guided paracentesis, ultrasound guided, needle, catheter, paracentesis, ultrasound, ascites |
3,478 | Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding. | Gastroenterology | Postop Transanal Excision | PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:, Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:, General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is ... | gastroenterology, diarrhea, anterior base lesion, polypoid lesion, transanal excision, transanal, anesthesia, bleeding, |
3,479 | Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation. | Gastroenterology | PEG Tube | PREOPERATIVE DIAGNOSIS:, Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: ,The patient is a 73-year-old male wh... | gastroenterology, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, peg tube, malnutrition, nutritional |
3,480 | Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. | Gastroenterology | Paracentesis | PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:, Paracentesis.,DESCRIPTION OF PROCEDURE: ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation. At the present time, the patient is under r... | gastroenterology, abdominal mass, clear fluid, cat scan, pigtail catheter, paracentesis, |
3,481 | Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. | Gastroenterology | Open Cholecystectomy | PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable c... | gastroenterology, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic, |
3,482 | Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. | Gastroenterology | Nissen Fundoplication | PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was i... | gastroenterology, umbilicus, insufflation, phrenoesophageal membrane, nissen fundoplication, gastric pouch, esophagus, penrose, antireflux, nissen, fundoplication, trocars, ligament, |
3,483 | Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation. | Gastroenterology | Proctitis & Proctocolitis | PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:, A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation. The patient states that he was well until about three days prior ... | null |
3,484 | The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. | Gastroenterology | Pancreatic Mass - Discharge Summary | HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreati... | gastroenterology, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage, |
3,485 | Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. | Gastroenterology | Progress Note - Liver Cirrhosis | HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the las... | gastroenterology, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis, |
3,486 | Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia,
and congestive heart failure. | Gastroenterology | Multiple Medical Problems - Discharge Summary | ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Co... | null |
3,487 | Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion. | Gastroenterology | Liver Biopsy | TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL: ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today. The patient was told of complic... | gastroenterology, bile peritonitis, bowel perforation, pneumothorax, klatskin needle, mid axillary, liver biopsy, percutaneous, lidocaine, biopsy, liver |
3,488 | Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. | Gastroenterology | Lower Quadrant Pain | REASON:, Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank. She states that is particularly bad when u... | null |
3,489 | Diagnostic laparoscopy and laparoscopic appendectomy. Right lower quadrant abdominal pain, rule out acute appendicitis. | Gastroenterology | Laparoscopy & Laparoscopic Appendectomy | PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMA... | gastroenterology, lower quadrant, diagnostic laparoscopy, acute appendicitis, laparoscopic appendectomy, abdomen, appendectomy, laparoscopy, appendix, suprapubic, |
3,490 | Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive ... | Gastroenterology | Melena - ICU Followup | HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic ob... | gastroenterology, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding |
3,491 | Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. | Gastroenterology | Laparoscopic Gastric Bypass - 1 | PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-o... | gastroenterology, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation |
3,492 | Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma. | Gastroenterology | Laparoscopy & Sigmoidoscopy | PREOPERATIVE DIAGNOSES:,1. Acute pain.,2. Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1. Acute pain.,2. Fever postoperatively.,3. Hemostatic uterine perforation.,4. No bowel or vascular trauma.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotrachea... | gastroenterology, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar, |
3,493 | Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct. | Gastroenterology | Laparoscopy, Laparotomy, & Cholecystectomy | PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operativ... | gastroenterology, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder |
3,494 | Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder. | Gastroenterology | Laparoscopic Cholecystectomy & Cholangiogram | PREOPERATIVE DIAGNOSIS:, Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS: ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallblad... | gastroenterology, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct, |
3,495 | Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. | Gastroenterology | Laparoscopic Cholecystectomy & Cholangiogram - 1 | PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was ... | gastroenterology, intraoperative cholangiogram, cystic artery, laparoscopic cholecystectomy, cystic duct, gallbladder, tonsil, cholecystectomy, cholangiogram, abdomen, laparoscopic, cannula, |
3,496 | Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. | Gastroenterology | Laparoscopic Gastric Bypass | PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS: ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for ma... | gastroenterology, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric |
3,497 | Laparoscopic cholecystectomy. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. | Gastroenterology | Laparoscopic Cholecystectomy - 9 | PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE: ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile mann... | gastroenterology, langer's lines, laparoscope, cystic duct, cystic artery, laparoscopic cholecystectomy, midline cannula, infraumbilical, tonsil, cholecystectomy, fascia, abdomen, trocars, cannula, laparoscopic, gallbladder, |
3,498 | Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. | Gastroenterology | Laparoscopic Cholecystectomy & Appendectomy | PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS: ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic chole... | gastroenterology, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct |
3,499 | Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. | Gastroenterology | Laparoscopic Cholecystectomy & Liver Cyst Excision | PREOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,3. Liver cyst.,PROCEDURES PERFORMED:,1. Laparoscopic cholecystectomy.,2. Excision of liver cyst.,ANESTHESIA: ,General endotracheal and injectable 0.25% Marcaine with 1% lido... | gastroenterology, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic, |
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