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3,800 | Patient today with ongoing issues with diabetic control. | Endocrinology | 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 ... | endocrinology, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses, |
3,801 | Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease. | Endocrinology | Axillary Dissection & Mass Excision | PREOPERATIVE DIAGNOSIS:, Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS: ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1. Left axillary dissection with incision and drainage of left axillary mass.,2. Right axillary mass excision and ... | endocrinology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary, |
3,802 | Urgent cardiac catheterization with coronary angiogram. | Emergency Room Reports | Urgent Cardiac Cath | PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lido... | emergency room reports, cardiac catheterization, coronary angiogram, angiogram |
3,803 | Followup diabetes mellitus, type 1. | Endocrinology | 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... | endocrinology, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars |
3,804 | This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills. | Emergency Room Reports | Viral Syndrome - ER Visit | SUBJECTIVE: ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT: Denies any severe headache or sore throat.,CHEST: No true p... | emergency room reports, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler, |
3,805 | Completion thyroidectomy with limited right paratracheal node dissection. | Endocrinology | Completion Thyroidectomy | TITLE OF OPERATION:, Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:, A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid... | endocrinology, multifocal thyroid carcinoma, thyroid lobectomy, thyroid, papillary, thyroid lobe, isthmus, completion thyroidectomy, thyroidectomy, paratracheal, lobectomy, |
3,806 | Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days.. | Emergency Room Reports | Toothache - ER Visit | CHIEF COMPLAINT:, Toothache.,HISTORY OF PRESENT ILLNESS: ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left s... | emergency room reports, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, |
3,807 | The patient has a possibly torsion detorsion versus other acute testicular problem. | Emergency Room Reports | Testicular Pain | CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Beca... | null |
3,808 | The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily. | Endocrinology | 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 |
3,809 | The patient had a syncopal episode last night. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations. | Emergency Room Reports | Syncope - ER Visit - 1 | REASON FOR VISIT:, Syncope.,HISTORY:, The patient is a 75-year-old lady who had a syncopal episode last night. She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor. She did not have any residual deficit. She had a headache at that ... | emergency room reports, residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope, |
3,810 | Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode. | Emergency Room Reports | Syncope - ER Visit | REASON FOR CONSULTATION:, Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode. According to the patient and t... | null |
3,811 | Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus. | Endocrinology | Acquired Hypothyroidism Followup | PROBLEM LIST:,1. Acquired hypothyroidism.,2. Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3. Diabetes mellitus.,4. Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 yea... | endocrinology, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism, |
3,812 | A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain. | Emergency Room Reports | Sickle Cell Anemia - ER Visit | HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a room mate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies an... | null |
3,813 | A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern. | Emergency Room Reports | Not Feeling Well - ER Visit | CHIEF COMPLAINT: ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:, This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generaliz... | null |
3,814 | This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. | Emergency Room Reports | Pain from Hernia - ER Consult | HISTORY OF PRESENT ILLNESS: ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has impro... | emergency room reports, blood in stool, nausea, capillary refill, angiogram, hernia, extremity, |
3,815 | Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation. | Emergency Room Reports | 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 |
3,816 | Nausea and feeling faint. She complains of some nausea. She feels weak. The patient is advised to put salt on her food for the next week. | Emergency Room Reports | Nausea - ER Visit | CHIEF COMPLAINT: , Nausea and feeling faint.,HPI: ,The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today, she complains of some nausea. She feels weak. No other specific complaints.,REVIE... | null |
3,817 | Penile injury and continuous bleeding from a penile laceration. | Emergency Room Reports | Penile Injury | REASON FOR ADMISSION:, Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:, The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding. He is otherwise healthy. He tried to insert a marble in his penis four days ago. He ... | null |
3,818 | Complete heart block with pacemaker malfunction and a history of Shone complex. | Emergency Room Reports | Shone complex | HISTORY AND PHYSICAL: ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block. He is on the pacemaker. He had a coarctation of the aorta and that was repaired when he was an infant. He was followed in our Cardiology Clinic here and has been doing well. However last night, h... | null |
3,819 | Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. | Emergency Room Reports | MRSA Infection - ER Visit | HISTORY OF PRESENT ILLNESS:, A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment nea... | null |
3,820 | Multiple contusions and abdominal pain, status post motor vehicle collision. | Emergency Room Reports | Motor Vehicle Accident | CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving he... | null |
3,821 | She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission. | Emergency Room Reports | Nausea & Vomiting - ER Visit | HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY:... | emergency room reports, iv hydration, elevated alt, emergency, nausea, vomiting, |
3,822 | Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. | Emergency Room Reports | Jaw Pain - ER Visit | CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointmen... | emergency room reports, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, |
3,823 | 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 ... | Emergency Room Reports | 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... | emergency room reports, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding |
3,824 | Patient presents to the Emergency Department with complaint of a bleeding bump on his penis. | Emergency Room Reports | Penile Mass - Emergency Visit | CHIEF COMPLAINT: , "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half... | emergency room reports, bump on penis, bleeding bump, glans, urethral meatus, penile mass, emergency department, penis, penile, pedunculated, bump, mass, |
3,825 | The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain. | Emergency Room Reports | Left Lower Quadrant Pain - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hour... | null |
3,826 | Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. | Emergency Room Reports | Mastoiditis - Discharge Summary | DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blo... | |
3,827 | This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. | Emergency Room Reports | Itchy Rash - ER Visit | CHIEF COMPLAINT:, Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breat... | emergency room reports, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, |
3,828 | Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. | Emergency Room Reports | Leaking Nephrostomy Tube | CHIEF COMPLAINT: ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. The leaking began this a.m. The patient denies any pain, does not have fever and has no other problems or... | emergency room reports, nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes, |
3,829 | Headache, improved. Intracranial aneurysm. | Emergency Room Reports | Intracranial aneurysm - ER Visit | CHIEF COMPLAINT:, Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently sche... | emergency room reports, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial, |
3,830 | An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation. | Emergency Room Reports | Hypertension - Consult | HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her beca... | emergency room reports, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, |
3,831 | The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. | Emergency Room Reports | Hydrocarbon Aspiration - ER Visit | SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration. The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of d... | null |
3,832 | Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea. | Emergency Room Reports | Hematuria - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on ... | null |
3,833 | Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur. | Emergency Room Reports | Hip Fracture - ER Consult | REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. History was obtained from the patient. As per ... | emergency room reports, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, |
3,834 | A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. | Emergency Room Reports | Hepatic Encephalopathy | REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. He said that he was doing fine prior to that and denied having any complaints. He w... | null |
3,835 | Migraine headache - The patient was seen in the urgent care. | Emergency Room Reports | Headache - Urgent Care Visit | CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches. ,PMH: , None. ,MEDICATIONS: ,T... | emergency room reports, photophobia, nausea, migraine headache, tylenol, migraine, headache, |
3,836 | Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. | Emergency Room Reports | High PT-INR - ER Visit | REASON FOR THE VISIT:, Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. She did not want to have Coumadin started because she said that she has had it before... | null |
3,837 | 4-day-old with hyperbilirubinemia and heart murmur. | Emergency Room Reports | Hyperbilirubinemia - 4-day-old | HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn a... | emergency room reports, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia, |
3,838 | Head injury, anxiety, and hypertensive emergency. | Emergency Room Reports | Head Injury | CHIEF COMPLAINT:, Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizz... | null |
3,839 | Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. | Emergency Room Reports | Gastrointestinal Bleed - ER Visit | ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS: ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell. She states that she woke yesterday morning and at approximately 10:30 had a bowel movement. She noticed it was very dark... | null |
3,840 | Patient dropped a weight on the dorsal aspects of his feet. | Emergency Room Reports | Foot Pain | CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an h... | null |
3,841 | Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm. | Emergency Room Reports | Headache - Emergency Visit | CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:, This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours... | null |
3,842 | The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. | Emergency Room Reports | Fall - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. The patient states that she was on the ladder on Saturday and she stepped down after the ladder. Felt some pain in her left ... | null |
3,843 | Vaginal discharge with a foul odor. | Emergency Room Reports | Gardnerella Bacterial Vaginosis | CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration. The patient states that she has also had frequency of urination. The p... | null |
3,844 | Patient in ER with upper respiratory infection | Emergency Room Reports | ER Report - URI | HISTORY OF PRESENT ILLNESS:, The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke... | emergency room reports, er, uri, emergency room, upper respiratory infection, respiratory, sick, fever, chest, |
3,845 | A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive. | Emergency Room Reports | Feeling Dizzy - ER Visit | REASON FOR CONSULTATION:, This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,PAST MEDICAL HISTORY: , Hypertension. The patient noncompliant,HISTORY OF PRESENT COMPLAINT: , This 66-year-old patient has history of hypertension and... | null |
3,846 | Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk. | Emergency Room Reports | Fall & Laceration | CC:, Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. H... | emergency room reports, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions, |
3,847 | Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire lef... | Emergency Room Reports | Fiberoptic Bronchoscopy with Lavage | PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respirator... | emergency room reports, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, venti... |
3,848 | Questionable foreign body, right nose. Belly and back pain. Mild constipation. | Emergency Room Reports | Foreign Body - Right Nose | CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels... | |
3,849 | Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. | Emergency Room Reports | ER Report - Stomach Pain | CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning... | null |
3,850 | Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. | Emergency Room Reports | Ecstasy Ingestion - ER Visit | CHIEF COMPLAINT:, "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. The patient upon returning to home w... | emergency room reports, nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy, |
3,851 | The patient is 14 months old, comes in with a chief complaint of difficulty breathing. | Emergency Room Reports | Difficulty Breathing - ER Visit | HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get wors... | null |
3,852 | This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. | Emergency Room Reports | Dental Pain | CHIEF COMPLAINT:, Dental pain.,HISTORY OF PRESENT ILLNESS:, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pa... | emergency room reports, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental, |
3,853 | Patient complains of chest pain - possible esophageal reflux | Emergency Room Reports | ER Report - Chest Pain | CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; howe... | null |
3,854 | A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. | Emergency Room Reports | ER Report - Chest Pain & Fever | CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly e... | null |
3,855 | This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology. | Emergency Room Reports | ER Report - Rib Cage Pain | HISTORY:, The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today. He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days. He denies any history of trauma. He does have incr... | null |
3,856 | Patient in ER complaining of shortness of breath (COPD) | Emergency Room Reports | ER Report - COPD | CHIEF COMPLAINT:, The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multipl... | null |
3,857 | Significant pain in left lower jaw. | Emergency Room Reports | Dental Pain - Emergency Visit | CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw. The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured. The patient ... | null |
3,858 | Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. | Emergency Room Reports | CVA Consult - ER Visit | ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this... | null |
3,859 | Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. | Emergency Room Reports | Consult - ICU Management | REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. T... | null |
3,860 | A female with unknown gestational age who presents to the ED after a suicide attempt. | Emergency Room Reports | Consult/ER Report - OB/GYN | The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period. She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus. She states that upon removal of a tampon, she saw a ta... | null |
3,861 | Status post colonoscopy. After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation. | Emergency Room Reports | 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 |
3,862 | Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma. | Emergency Room Reports | Chest Tube Insertion in ER | PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.... | emergency room reports, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion, |
3,863 | 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. | Emergency Room Reports | 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... | emergency room reports, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body, |
3,864 | Status post a high-speed motor vehicle accident in which patient was ejected from the vehicle. | Emergency Room Reports | Closed Head Injury | CHIEF COMPLAINT:, Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle. He denies loss of consciousness, although the EMT people report that he did have loss of consciou... | null |
3,865 | 2-month-old female - increased work of breathing. | Emergency Room Reports | Bronchiolitis - 2-month-old | CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night... | null |
3,866 | Patient in ER due to colostomy failure - bowel obstruction. | Emergency Room Reports | 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 |
3,867 | Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed. | Emergency Room Reports | 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 |
3,868 | Mother states he has been wheezing and coughing. | Emergency Room Reports | Asthma in a 5-year-old | CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asth... | null |
3,869 | Acute foot or ankle sprain, possible small fracture. | Emergency Room Reports | Ankle pain | CHIEF COMPLAINT:, Ankle pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts t... | emergency room reports, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture, |
3,870 | 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. | Emergency Room Reports | 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 |
3,871 | Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin. | Emergency Room Reports | Angina - Consult | HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call ... | null |
3,872 | The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone. | Emergency Room Reports | Airway Compromise & Foreign Body - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterect... | emergency room reports, diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway, |
3,873 | 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. | Emergency Room Reports | 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... | emergency room reports, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms, |
3,874 | A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the diagnosis of intracranial bleeding. | Emergency Room Reports | Altered Mental Status - ER Visit | CHIEF COMPLAINT: , Altered mental status.,HISTORY OF PRESENT ILLNESS: , This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding. The patient was found by the 8-year-old sister in the bathroom. He was laying down on one side, and he was crying and moaning. The... | emergency room reports, arteriovenous malformation, stroke, traumatic injury, intracerebral hemorrhage, altered mental status, crying and moaning, mental status, intracranial bleeding, icu attendings, emergency, intracranial, neurosurgery, gastroesophageal, intracerebrally, bleeding, icu, |
3,875 | 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. | Emergency Room Reports | 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 |
3,876 | Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility. | Emergency Room Reports | Agitation - ER Visit | HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated... | emergency room reports, acute episode of agitation, agitation, |
3,877 | The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions. | Discharge Summary | Speech Therapy - Discharge Summary - 2 | The patient made some progress during therapy. She accomplished two and a half out of her five short-term therapy goals. We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits. The patient improved on her turn taking skills during con... | discharge summary, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy... |
3,878 | 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. | Emergency Room Reports | 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... | emergency room reports, accidental ingestion of celesta, celesta, tablets, ingestion, |
3,879 | A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain. | Emergency Room Reports | Abrasions & Lacerations - ER Visit | HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, ... | null |
3,880 | Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus. | Discharge Summary | TAH - Discharge Summary | ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Symptomatic fibroid uterus.,4. Extensive adenomyosis by pathological report.,OPER... | discharge summary, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal, |
3,881 | Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. | Discharge Summary | Urology Discharge Summary | PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lun... | discharge summary, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate |
3,882 | Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction. | Emergency Room Reports | Acute Inferior Myocardial Infarction | CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has ... | null |
3,883 | The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. | Emergency Room Reports | 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 |
3,884 | Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension. | Discharge Summary | Renal Disease - Discharge Summary | ADMISSION DIAGNOSES:,1. Syncope.,2. End-stage renal disease requiring hemodialysis.,3. Congestive heart failure.,4. Hypertension.,DISCHARGE DIAGNOSES:,1. Syncope.,2. End-stage renal disease requiring hemodialysis.,3. Congestive heart failure.,4. Hypertension.,CONDITION ON DISCHARGE: , Stable.,PROCEDURE PERFORME... | discharge summary, syncope, congestive heart failure, end-stage renal disease requiring hemodialysis, nuclear medicine, stress test, stage renal, renal disease, renal, disease, hemodialysis, |
3,885 | The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. | Discharge Summary | Speech Therapy - Discharge Summary - 1 | HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial spe... | discharge summary, communication skills, g-tube, aphasia, language evaluation, western aphasia battery, skilled speech therapy, swallowing function, speech therapy, therapy, swallowing, aspiration, speech, communication, |
3,886 | The patient was discharged by court as a voluntary drop by prosecution. | Discharge Summary | Psychiatric Discharge Summary | DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , Th... | discharge summary, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis, |
3,887 | Discharge summary of a patient with depression and high risk behavior. | Discharge Summary | Psychiatric Discharge Summary - 2 | DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1. | null |
3,888 | Speech therapy discharge summary. The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. | Discharge Summary | Speech Therapy - Discharge Summary | LONG-TERM GOALS:, Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community. This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home. During the last reevaluation, the patien... | discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and qu... |
3,889 | Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year. | Discharge Summary | Pyelonephritis - Discharge Summary | ADMISSION DIAGNOSES:,1. Pyelonephritis.,2. History of uterine cancer and ileal conduit urinary diversion.,3. Hypertension.,4. Renal insufficiency.,5. Anemia.,DISCHARGE DIAGNOSES:,1. Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2. Hypertension.,3. Mild renal insuff... | discharge summary, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit |
3,890 | Discharge summary of a patient with mood swings and oppositional and defiant behavior. | Discharge Summary | Psychiatric Discharge Summary - 1 | DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1. | null |
3,891 | Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem. | Discharge Summary | Prematurity - Discharge Summary | ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS: ,This i... | null |
3,892 | 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. | Discharge Summary | 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... | discharge summary, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage, |
3,893 | Fever, otitis media, and possible sepsis. | Discharge Summary | Otitis Media - Discharge Summary | ADMITTING DIAGNOSES:,1. Fever.,2. Otitis media.,3. Possible sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal cong... | discharge summary, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever |
3,894 | Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy. | Discharge Summary | ORIF - Discharge Summary | ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:, Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: ... | discharge summary, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau, |
3,895 | Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures ... | Discharge Summary | Pneumonia & COPD - Discharge Summary | ADMISSION DIAGNOSES:,1. Pneumonia, likely secondary to aspiration.,2. Chronic obstructive pulmonary disease (COPD) exacerbation.,3. Systemic inflammatory response syndrome.,4. Hyperglycemia.,DISCHARGE DIAGNOSES:,1. Aspiration pneumonia.,2. Aspiration disorder in setting of severe chronic obstructive pulmonary dis... | null |
3,896 | Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion. | Discharge Summary | Neurology - Discharge Summary | PRELIMINARY DIAGNOSES:,1. Contusion of the frontal lobe of the brain.,2. Closed head injury and history of fall.,3. Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1. Contusion of the orbital surface of the frontal lobes bilaterally.,2. Closed head injury.,3. History of fall.,COURSE IN THE HOSPITAL: ,... | discharge summary, interhemispheric, frontal lobe, head injury, brain, contusion |
3,897 | Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain. | Discharge Summary | Occupational Therapy Discharge Summary | DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional... | discharge summary, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation, |
3,898 | Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. | Discharge Summary | Pneumonia - Discharge Summary | ADMISSION DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had s... | discharge summary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, |
3,899 | Symptomatic thyroid goiter. Total thyroidectomy. | Discharge Summary | Post Thyroidectomy - Discharge Summary | ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS: ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY: ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. ... | discharge summary, nodular, symptomatic thyroid goiter, thyroidectomy, goiter, |
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