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3,600 | Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. | Gastroenterology | CT Abdomen & Pelvis - 9 | CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:, Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, adrenal glands, and kidneys are u... | gastroenterology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue, |
3,601 | Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast. | Gastroenterology | CT Abdomen & Pelvis - OB-GYN | EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDING... | gastroenterology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen |
3,602 | Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained. | Gastroenterology | CT Abdomen & Pelvis - 7 | REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lu... | gastroenterology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast |
3,603 | Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. | Gastroenterology | CT Abdomen & Pelvis - 6 | REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the... | gastroenterology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct |
3,604 | CT abdomen without contrast and pelvis without contrast, reconstruction. | Gastroenterology | CT Abdomen & Pelvis - 5 | EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is norma... | gastroenterology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast, |
3,605 | CT abdomen and pelvis without contrast, stone protocol, reconstruction. | Gastroenterology | CT Abdomen & Pelvis - 4 | EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatatio... | gastroenterology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncont... |
3,606 | CT of the abdomen and pelvis without contrast. | Gastroenterology | CT Abdomen & Pelvis - 3 | EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:, Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the s... | gastroenterology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen, |
3,607 | Patient presents for a colostomy reversal as well as repair of an incisional hernia. | Gastroenterology | Consult for Colostomy Reversal | CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital wi... | null |
3,608 | CT Abdomen & Pelvis W&WO Contrast | Gastroenterology | CT Abdomen & Pelvis | EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison i... | gastroenterology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen, |
3,609 | Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. | Gastroenterology | Consult - Rectal Bleeding | PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. The patient states that he had his first colonoscopy 6 year... | gastroenterology, heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer, |
3,610 | Patient comes for discussion of a screening colonoscopy. | Gastroenterology | Consult - Screening Colonoscopy | HISTORY:, A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been a... | gastroenterology, screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy, |
3,611 | Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast. | Gastroenterology | CT Abdomen & Pelvis - 11 | EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen... | gastroenterology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen, |
3,612 | A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future. | Gastroenterology | Consult - Multiple Colon Polyps | HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTOR... | gastroenterology, mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps, |
3,613 | Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast. | Gastroenterology | CT Abdomen & Pelvis - 10 | CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable. Within the ... | gastroenterology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen, |
3,614 | CT scan of the abdomen and pelvis without and with intravenous contrast. | Gastroenterology | CT Abdomen & Pelvis - 2 | EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. O... | gastroenterology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen, |
3,615 | CT Abdomen and Pelvis with contrast | Gastroenterology | CT Abdomen & Pelvis - 1 | EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bas... | gastroenterology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct |
3,616 | Patient in ER due to colostomy failure - bowel obstruction. | Gastroenterology | Colostomy Failure | CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He de... | null |
3,617 | Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones. | Gastroenterology | Consult - Laparoscopic Cholecystectomy | PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed. She is married. She is in sales. She does not smoke. She drinks wine a few drinks a month.,CURRENT MEDICATIONS: ,... | gastroenterology, laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal |
3,618 | Patient complains of constipation. Has not had BM for two days. | Gastroenterology | Constipation - 1 | Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General: Pleasant, brighter.,Vital signs: 117/78, 12, 56.,Abdomen: Soft, nontender. Bowel sounds normal.,ASSESSMENT AND PLAN:,1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a w... | gastroenterology, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema, |
3,619 | Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now be... | Gastroenterology | Colonoscopy With Photos | PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Diverticulosis coli.,2. Internal hemorrhoids.,3. Poor prep.,PROCEDURE PERFORMED:, Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:, None.,HISTORY:, The patient is an 85-year-old female who was admitted to ... | gastroenterology, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope |
3,620 | Colonoscopy with random biopsies and culture. | Gastroenterology | Colonoscopy with Biopsy - 4 | PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea. ,POSTOPERATIVE DIAGNOSIS: ,Antibiotic-associated diarrhea. ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago. She has been having ... | gastroenterology, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy |
3,621 | Common description of colonoscopy | Gastroenterology | Colonoscopy Template - 2 | null | gastroenterology, cecum, retroflexion, colon, tumor, polyp, mass, ulceration, tip, endoscope, inserted, colonoscopyNOTE,: 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... |
3,622 | The patient with a recent change in bowel function and hematochezia. | Gastroenterology | Colonoscopy with Biopsy - 1 | PREPROCEDURE DIAGNOSIS:, Change in bowel function.,POSTPROCEDURE DIAGNOSIS:, Proctosigmoiditis.,PROCEDURE PERFORMED:, Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable. ,INDICATIONS:, The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is he... | gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia, |
3,623 | Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon. | Gastroenterology | Colonoscopy with Biopsy - 3 | PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon. | gastroenterology, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope, |
3,624 | Common description of colonoscopy | Gastroenterology | Colonoscopy Template - 4 | A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve. This was done without difficulty and the bowel preparation was good. The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was ins... | gastroenterology, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not cert... |
3,625 | Small internal hemorrhoids and Ileal colonic anastomosis. | Gastroenterology | Colonoscopy with Biopsy - 2 | PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:, The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted app... | gastroenterology, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy |
3,626 | Common description of colonoscopy | Gastroenterology | Colonoscopy Template - 3 | null | gastroenterology, left lateral sims position, cecum, mass, lesions, mucosal abnormalities, friability, polyps, endoscopy suite, endoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and qua... |
3,627 | A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia. | Gastroenterology | Colonoscopy with Biopsy | INDICATIONS FOR PROCEDURE: , A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.,DESCRIPTION OF PROCEDURE: , The patient was explained the procedure in detail, possible complications including infec... | gastroenterology, olympus video colonoscope, advanced to the cecum, heme-positive stools, diverticular change, colitis, colonoscopy to the cecum, spastic colon, colonoscopy with biopsy, liver disease, biopsy, hepatitis, chronic, liver, disease, mucosa, polyp, rectal, colonoscopy, |
3,628 | Colonoscopy, conscious sedation, and snare polypectomy. | Gastroenterology | Colonoscopy & Polypectomy - 2 | PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS: ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy. ,INDICATIONS: ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy. H... | gastroenterology, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy, |
3,629 | Common description of colonoscopy | Gastroenterology | Colonoscopy Template - 5 | null | gastroenterology, cecum, colonoscope, digital rectal examination, colonoscopyNOTE,: 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 transcripti... |
3,630 | Total colonoscopy and polypectomy | Gastroenterology | Colonoscopy & Polypectomy - 1 | PREOPERATIVE DIAGNOSIS:, History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:, IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems wi... | gastroenterology, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent, |
3,631 | Total colonoscopy with biopsy and snare polypectomy. | Gastroenterology | Colonoscopy & Polypectomy - 3 | PREOPERATIVE DIAGNOSIS:, Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:, 4/4.,DIFFICULTY:, 1/4.,PREMEDICATION AND SEDATION: , Fentan... | gastroenterology, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid, |
3,632 | Common description of colonoscopy | Gastroenterology | Colonoscopy Template - 1 | null | gastroenterology, decubitus position, cecum, colonic mucosa, ileocecal, rectum, colonoscopy, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These tran... |
3,633 | Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy. | Gastroenterology | Colonoscopy - 8 | PROCEDURES PERFORMED:, Colonoscopy.,INDICATIONS:, Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to be... | gastroenterology, sulfasalazine cortisone local therapy, inflammatory bowel disease, cortisone local, local therapy, crohn disease, sigmoid colon, bowel disease, colonoscopy, inflammatory, rectal, sulfasalazine, cecum, sigmoid, bowel, disease |
3,634 | Colonoscopy - Diarrhea, suspected irritable bowel | Gastroenterology | Colonoscopy - 4 | PREOPERATIVE DIAGNOSIS:, Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:, Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:, The rectal exam revealed no external lesions. The prostate was normal in size and consistency.,The colonoscope was inserted into the cecu... | gastroenterology, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel,... |
3,635 | Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.
| Gastroenterology | Colonoscopy & Esophagogastroduodenoscopy | PREOPERATIVE DIAGNOSES:,1. Hematochezia.,2. Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Colonic polyps at 35 cm and 15 cm.,2. Diverticulosis coli.,2. Acute and chronic gastritis.,PROCEDURE PERFORMED:,1. Colonoscopy to cecum with snare polypectomy.,2. Esophagogastroduodenoscopy with biopsies.,INDICATIONS FO... | gastroenterology, endoscopy, olympus colonoscope, snare polypectomy, ge junction, refractory dyspepsia, colonic polyps, diverticulosis coli, chronic gastritis, esophagogastroduodenoscopy, snare, biopsies, dyspepsia, gastritis, diverticulosis, polypectomy, colonoscopy, hematochezia, polyps |
3,636 | Colonoscopy due to hematochezia and personal history of colonic polyps. | Gastroenterology | Colonoscopy - 5 | PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:, Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:, A History and Physical has been performed, and patient medication allergies have been reviewed. The patient's tolerance of previous anesthesia has been reviewed.... | null |
3,637 | Patient with history of polyps. | Gastroenterology | Colonoscopy - 9 | PREOPERATIVE DIAGNOSIS:, Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:, Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:, The rectal chamber revealed no external lesions. Prostate was normal in size and consistency.,The ... | gastroenterology, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy, |
3,638 | Patient with history of adenomas and irregular bowel habits. | Gastroenterology | Colonoscopy - 7 | PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1. Two colon polyps, removed.,2. Small internal hemorrhoids.,3. Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with ... | gastroenterology, colon polyps, internal hemorrhoids, rectum, irregular bowel habits, colon polyps removed, irregular bowel, bowel habits, polyps removed, bowel, habits, colonoscope, hemorrhoids, cecum, forceps, polyps, colonoscopy, adenomas, |
3,639 | Colonoscopy to evaluate prior history of neoplastic polyps. | Gastroenterology | Colonoscopy - 3 | PREOPERATIVE DIAGNOSIS:, Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:, Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:, Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill. I asked the nurse to give her 25 mg of Demerol IV.... | gastroenterology, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope |
3,640 | Colonoscopy to screen for colon cancer | Gastroenterology | Colonoscopy - 6 | INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED: ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:, The tip of the endoscope was introduc... | gastroenterology, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy, |
3,641 | Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years. | Gastroenterology | Colonoscopy - 20 | PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:, Tiny Polyps.,PROCEDURE PERFORMED: , Colonoscopy.,PROCEDURE: , The procedure, indications, and risks were explained to the patient, who understood and agreed. He was sedated with Versed 3 mg, Demerol 25 mg during the examination. ,A digital rectal exam... | gastroenterology, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy |
3,642 | Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps. | Gastroenterology | Colonoscopy - 21 | OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1. Colon cancer screening.,2. Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Multiple colon polyps (5).,2. Diverticulosis, sigmoid colon.,3. Internal hemorrho... | gastroenterology, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy, |
3,643 | Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy. | Gastroenterology | Colonoscopy - 22 | PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:, The patient is a 56-year-old female. She was referred for a screening colonoscopy. The patient has bowel movements every other day. There is no blood in the stool, no abdominal pain. She has hypertension, dyslipidemia, and gastroesophageal reflux disease. She has... | gastroenterology, screening colonoscopy, colon cancer, colonoscopy, polyps, malignancy, sigmoid, rectum, cecum, diverticulosis |
3,644 | Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. | Gastroenterology | Colonoscopy - 19 | INDICATION: , Iron deficiency anemia.,PROCEDURE: ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:, Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL: ,Following the preprocedure patient assessment the proced... | gastroenterology, polyp, endoscope, mucosa, iron deficiency anemia, ileocecal valve, terminal ileum, colonoscopy, anemia, rectum, ileum |
3,645 | Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck. | Gastroenterology | Colonoscopy - 17 | PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Universal diverticulosis.,2. Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:, Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,... | gastroenterology, endoscopy, rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon, total colonoscopy, colon polyps, colonoscopy, cecum, polyps, diverticulosis, hemorrhoids, |
3,646 | Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy. | Gastroenterology | Colonoscopy - 18 | PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED: ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease.... | gastroenterology, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel, |
3,647 | Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids. | Gastroenterology | Colonoscopy - 14 | PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluat... | gastroenterology, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid |
3,648 | Colonoscopy in a patient with prior history of anemia and abdominal bloating. | Gastroenterology | Colonoscopy - 2 | PREOPERATIVE DIAGNOSES:, Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:, External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:, Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:, Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the re... | gastroenterology, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope, |
3,649 | Colonoscopy. Rectal bleeding and perirectal abscess. Normal colonoscopy to the terminal ileum. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen. | Gastroenterology | Colonoscopy - 16 | PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum an... | gastroenterology, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess |
3,650 | History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy. | Gastroenterology | Colonoscopy - 13 | PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1. Normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of... | gastroenterology, digital examination, benign prostatic hypertrophy, anorectal canal, diverticular disease, photography, anorectal, colonoscopy, |
3,651 | Colonoscopy. Change in bowel habits and rectal prolapse. Normal colonic mucosa to the cecum. | Gastroenterology | Colonoscopy - 15 | PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve... | gastroenterology, olympus, colonoscope, bowel habits, colonic mucosa, colonic, rectum, rectal, cecum, mucosa, colonoscopy, |
3,652 | Routine colorectal cancer screening. He occasionally gets some loose stools. | Gastroenterology | 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... | gastroenterology, colon cancer screening, loose stools, colorectal, colonoscopy, |
3,653 | Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids. | Gastroenterology | Colonoscopy - 10 | PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:, Colonic polyps.,PROCEDURE:, Colonoscopy.,ANESTHESIA:, MAC,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the ce... | gastroenterology |
3,654 | Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. | Gastroenterology | Colonoscopy - 12 | PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of... | gastroenterology, ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, rectum, terminal ileum, olympus video colonoscope, flexure, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users an... |
3,655 | Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. | Gastroenterology | Colonoscopy - 11 | MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications. The Olympus video colonoscope was inserted through the anus and was advanced in re... | gastroenterology, olympus, scope, sigmoid colon, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon, ileocecal valve, ileocecal, mucosa, rectum, colonoscope, flexure, cecum, colonoscopyNOTE |
3,656 | 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. | Gastroenterology | 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 |
3,657 | Still having diarrhea, decreased appetite. | Gastroenterology | Clostridium Difficile Colitis Followup | SUBJECTIVE: ,The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile.,PHYSICAL EXAMINATION,GENERAL: Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS: Blood pressure 102/64, heart rate of 89, respira... | gastroenterology, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis, |
3,658 | Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease. | Gastroenterology | Colonoscopy - 1 | INDICATION: , Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE: , | gastroenterology, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory |
3,659 | 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. | Gastroenterology | 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... | gastroenterology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps, |
3,660 | Iron deficiency anemia. Diverticulosis in the sigmoid. | Gastroenterology | Colonoscopy | PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and th... | gastroenterology, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy |
3,661 | Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis. | Gastroenterology | Cholecystostomy Tube Placement | PREOPERATIVE DIAGNOSIS:, Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:, Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week sta... | gastroenterology, under ultrasound guidance, cholecystostomy tube, acalculous cholecystitis, catheter, cholecystostomy, ultrasound, acalculous, cholecystitis |
3,662 | Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction. | Gastroenterology | Cholecystitis - Discharge Summary | REASON FOR ADMISSION: , Cholecystitis with choledocholithiasis.,DISCHARGE DIAGNOSES: , Cholecystitis, choledocholithiasis.,ADDITIONAL DIAGNOSES,1. Status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2. Laparoscopic paraventral hernia in 11/07.,3. History of sleep apnea with reversal after 1... | gastroenterology, laparoscopy, common bile duct exploration, laparoscopic cholecystectomy, bile duct, choledocholithiasis, cholecystectomy, cholecystitis, laparoscopic, hernia |
3,663 | Laparoscopic cholecystectomy with cholangiogram. | Gastroenterology | Cholecystectomy & Cholangiogram. | PREOPERATIVE DIAGNOSES:,1. Cholelithiasis.,2. Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic cholecystitis.,2. Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with... | gastroenterology, cholelithiasis, acute cholecystitis, laparoscopic, cholecystectomy, cholangiogram, laparoscopic cholecystectomy, gallbladder, |
3,664 | Status post colonoscopy. After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation. | Gastroenterology | Blood per Rectum | CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during th... | null |
3,665 | Laparoscopic resection of cecal polyp. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps. | Gastroenterology | Cecal Polyp Resection | PREOPERATIVE DIAGNOSIS:, Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA: ,General oral endotracheal intubation.,PROCEDURE:, After adequate general anesthesia was administered the patient's abdomen was prepped and draped ase... | gastroenterology, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic |
3,666 | 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. | Gastroenterology | 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 |
3,667 | Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. | Gastroenterology | Cholecystectomy Laparoscopic | PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: ... | gastroenterology, gallstone, gallbladder, pancreatitis, anterior abdominal wall, video laparoscope, laparoscopic cholecystectomy, omental adhesions, veress needle, cystic duct, injectable, adhesions, cholecystectomy, laparoscopic, abdomen |
3,668 | 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. | Gastroenterology | 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... | |
3,669 | Open cholecystectomy (attempted laparoscopic cholecystectomy). | Gastroenterology | Cholecystectomy - Open | PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, ... | gastroenterology, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french, |
3,670 | Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed. | Gastroenterology | 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 |
3,671 | Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals. | Gastroenterology | Barium Swallow Study Evaluation | HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and ch... | gastroenterology, globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods, |
3,672 | The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration. | Gastroenterology | Barium Swallow Study Evaluation - 1 | HISTORY: ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study. The patient stated that the results of that modified revealed aspiration with thin liquids ... | gastroenterology, oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing, |
3,673 | Barium enema - history of encopresis and constipation. | Gastroenterology | Barium Enema | EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic ... | gastroenterology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium, |
3,674 | Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis. | Gastroenterology | Appendectomy - Laparoscopic | PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSES:,1. Pelvic inflammatory disease.,2. Periappendicitis.,PROCEDURE PERFORMED:,1. Laparoscopic appendectomy.,2. Peritoneal toilet and photos.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Less than 10 cc.,INDICATIONS FOR PROCE... | gastroenterology, acute appendicitis, periappendicitis, peritoneal toilet, pelvic inflammatory disease, abdominal wall, direct visualization, toilet, appendectomy, mesoappendix, laparoscopic, port, inflammatory |
3,675 | Hematemesis in a patient with longstanding diabetes. Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis. Mallory-Weiss tear, successful BICAP cautery. | Gastroenterology | BICAP Cautery | PREOPERATIVE DIAGNOSIS: , Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS: ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE: , The procedure, indications explained and he understood and agreed. He was sedated with Versed... | gastroenterology, mallory-weiss tear, submucosal hemorrhage, esophagitis, vomiting, bicap cautery, mallory weiss, diabetes, esophagus, submucosal, hemorrhage, trauma, hematemesis, |
3,676 | Appendicitis, nonperforated. Appendectomy. A transverse right lower quadrant incision was made directly over the point of maximal tenderness. | Gastroenterology | Appendectomy | PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis, nonperforated.,PROCEDURE PERFORMED:, Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General end... | gastroenterology, peritoneal cavity, peritoneal fluid, abdominal cavity, abdominis muscle, transversalis fascia, peritoneum, internal oblique fascia, vicryl ties, appendectomy, appendicitis, appendix, |
3,677 | Acute appendicitis, gangrenous. Appendectomy. | Gastroenterology | Appendectomy - 1 | PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions. After having obtained an informed consent, he was placed in the operating room and under a... | gastroenterology, mcburney incision, abdominal, small bowel, acute appendicitis, appendectomy, gangrenous, appendix, |
3,678 | The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing. | Gastroenterology | Barium Swallow Study & Speech Evaluation | CURRENT MEDICATIONS:, Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY: ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed ... | null |
3,679 | Gastroenterology | Barium Swallow Study & Speech Evaluation - 1 | SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heart... | gastroenterology, gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration | |
3,680 | Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. | Gastroenterology | Appendectomy Laparoscopic - 1 | PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:, This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2... | gastroenterology, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis |
3,681 | 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. | Gastroenterology | 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 |
3,682 | Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal. | Gastroenterology | 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 ... | gastroenterology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia, |
3,683 | The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. | Gastroenterology | 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 |
3,684 | Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia. | Gastroenterology | Abscess Excision | PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1. Abscess secondary to retained foreign body.,2. Incisional hernia.,PROCEDURES,1. Excision of abscess, removal of foreign body.,2. Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant... | gastroenterology, sebaceous cyst, prolene suture, incisional hernia, incisional, abscess, hernia, abdomen, omentum, excision, cyst, |
3,685 | Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain. | Gastroenterology | 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 ... | gastroenterology, gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery, |
3,686 | Laparoscopic appendectomy. Acute appendicitis. | Gastroenterology | Appendectomy Laparoscopic | PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,PROCEDURE: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain. History as wel... | gastroenterology, endo gia, babcock's, laparoscopic appendectomy, direct vision, abdominal cavity, acute appendicitis, appendectomy, hemostasis, laparoscopic, infraumbilical, appendix, appendicitis, endotracheal, |
3,687 | The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness. | ENT - Otolaryngology | Vertigo Consult - 1 | Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,RO... | ent - otolaryngology, tinnitus, deafness, imbalance, nystagmus, hypofunction, electronystagmography, vertigo, vestibular, |
3,688 | Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body. | Gastroenterology | Abdominal Abscess I&D | PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient... | gastroenterology, excisional debridement, subcutaneous tissue, abdominal wall abscess, foreign body, abdominal abscess, bovie cautery, abdominal, i&d, wound, incision, abscess, |
3,689 | Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak. Diffuse intestinal and mesenteric lymphangiectasia. | Gastroenterology | Abdominal Exploration | PREOPERATIVE DIAGNOSES: ,1. Congenital chylous ascites and chylothorax.,2. Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION: ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most... | gastroenterology, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic |
3,690 | Uvulopalatopharyngoplasty and tonsillectomy. The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea. | ENT - Otolaryngology | Uvulopalatopharyngoplasty & Tonsillectomy | PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS: ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1. Tonsillectomy.,2. Uvulopalatopharyngoplasty.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history o... | ent - otolaryngology, endotracheal, metzenbaum, soft palate, obstructive sleep apnea, tonsillectomy, uvulopalatopharyngoplasty, obstructive, mucosa, uvula, palate, |
3,691 | Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. | ENT - Otolaryngology | Tympanostomy & Myringotomy Tube Placement | PREOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA: ,Total IV gener... | ent - otolaryngology, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy |
3,692 | The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment. | ENT - Otolaryngology | Vertigo Consult | Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX... | ent - otolaryngology, electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo, |
3,693 | Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy. | ENT - Otolaryngology | Tympanostomy | PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:, Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1. Tympanostomy and tube placement.,2. Adenoidectomy.,ANESTHESIA: ,General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was take... | ent - otolaryngology, robinson catheters, palate, tongue, tympanostomy, adenoidectomy, chronic otitis media, oral cavity, adenotonsillar hypertrophy, tube placement, hypertrophy, nasopharynx, adenotonsillar, |
3,694 | Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. | ENT - Otolaryngology | URI & Eustachian Congestion | HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting o... | ent - otolaryngology, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar |
3,695 | Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum | ENT - Otolaryngology | Tonsillectomy and Septoplasty | PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:, Tonsillectomy, uvulopalatopharyngoplasty,... | ent - otolaryngology, obstructive sleep apnea syndrome, afrin drops, bayonet cautery, cpap, cottle elevator, crowe-davis, freer elevator, obstructive sleep apnea, tonsillectomy, hypertrophy, mouth gag, nasal, nasal passage, nasal septum, nasopharynx, nostrils, palate, pharynx, septal cartilage, septoplasty, sleep apnea... |
3,696 | Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes. | ENT - Otolaryngology | Tracheostomy & Thyroid Isthmusectomy | PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less... | ent - otolaryngology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy |
3,697 | Tonsillectomy and adenoidectomy. Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis. | ENT - Otolaryngology | Tonsillectomy & Adenoidectomy - 3 | PREOPERATIVE DIAGNOSIS:, Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGIC... | ent - otolaryngology, obstructive adenotonsillar hypertrophy, pharyngitis, tonsillectomy, adenoidectomy, uvula, obstructive, adenotonsillar, hypertrophy, hypertrophic, fossa, tonsils, oropharynx, electrocautery, pads |
3,698 | Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours. | ENT - Otolaryngology | Tympanomastoidectomy | PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1. Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2. Microdissection.,3. NIM facial nerve monitoring for three hours.,COMPLICATIONS: ,None.,FINDINGS:, There ... | ent - otolaryngology, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear, |
3,699 | Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. | ENT - Otolaryngology | Tonsillectomy & Adenoidectomy - 5 | POSTOPERATIVE DIAGNOSIS:, Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: ,General endotracheal tube.,ESTIMATED BLOOD LOSS:, Minimum, less than 5 cc.,SPECIMENS:, Right and left tonsils 2+, adenoid pad 1+. There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: ,... | ent - otolaryngology, chronic adenotonsillitis, tonsillectomy, adenoidectomy, adenoid, tonsils, tonsillar fossa, tonsillar fossae, suction cautery, adenotonsillitis, oropharynx, hemostasis, cautery, suction, tonsillar |
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