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3,900 | 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. | Discharge Summary | 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... | |
3,901 | Discharge summary of a patient presenting with a large mass aborted through the cervix. | Discharge Summary | Mullerian Adenosarcoma | PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma. ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST: Clear. There is no heart murmur.,ABDOMEN: Nontender.,PELVIC: There is a large mass in the vagina. ,HOSPITAL COURSE: , The patien... | discharge summary, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma |
3,902 | Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. | Discharge Summary | Neonatal Discharge Summary - 1 | ADMITTING DIAGNOSES:, Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. Baby was born at ABCD Hospital at 1333 on 07/14/2006. Mother i... | discharge summary, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant, |
3,903 | Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia. | Discharge Summary | Leiomyosarcoma | ADMITTING DIAGNOSES:,1. Leiomyosarcoma.,2. History of pulmonary embolism.,3. History of subdural hematoma.,4. Pancytopenia.,5. History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2. CTA, chest PE study showing no evidenc... | discharge summary, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary, |
3,904 | Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia,
and congestive heart failure. | Discharge Summary | Multiple Medical Problems - Discharge Summary | ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Co... | null |
3,905 | Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. | Discharge Summary | Laryngitis - Discharge | DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY: ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused... | discharge summary, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis |
3,906 | The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. | Discharge Summary | Neonatal Discharge Summary | HOSPITAL COURSE:, The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5:57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions, with pr... | discharge summary, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge, |
3,907 | Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis. | Discharge Summary | Neck Pain - Discharge Summary | ADMISSION DIAGNOSES,1. Neck pain with right upper extremity radiculopathy.,2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1. Neck pain with right upper extremity radiculopathy.,2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, a... | discharge summary, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated, |
3,908 | Decreased ability to perform daily living activities secondary to right knee surgery. | Discharge Summary | Knee Surgery - Discharge Summary | CHIEF COMPLAINT:, Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patien... | null |
3,909 | This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. | Discharge Summary | Kawasaki Disease - Discharge Summary | ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated ne... | discharge summary, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin |
3,910 | Total vaginal hysterectomy. Microinvasive carcinoma of the cervix. | Discharge Summary | Hysterectomy - Discharge Summary - 2 | ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation. ... | discharge summary, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix, |
3,911 | Laparoscopic cholecystectomy. Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism. | Discharge Summary | Lap Chole - Discharge Summary | PROCEDURE:, Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1. Acute cholecystitis.,2. Status post laparoscopic cholecystectomy.,3. End-stage renal disease on hemodialysis.,4. Hyperlipidemia.,5. Hypertension.,6. Congestive heart failure.,7. Skin lymphoma 5 years ago.,8. Hypothyroidism.,HOSPITAL COURSE: , Th... | discharge summary, end-stage renal disease, lymphoma, cholecystitis, congestive heart failure, skin lymphoma, gallbladder wall, laparoscopic cholecystectomy |
3,912 | Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty. | Discharge Summary | Knee Arthroplasty - Discharge Summary | ADMISSION DIAGNOSIS:, Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:, Status post poly exchange, right knee, total knee ... | discharge summary, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty, |
3,913 | A 66-year-old female with knee osteoarthrosis who failed conservative management. | Discharge Summary | Knee Osteoarthrosis - Discharge Summary | PRINCIPAL DIAGNOSIS:, Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:, A 66-year-old female with knee osteoarthrosis. Failed conservative management. Risks and benefits of different treatment options were explained. Informed consent was obtained.,PAST SURGICAL HISTORY: , ... | discharge summary, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee, |
3,914 | Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids. | Discharge Summary | Hysterectomy - Discharge Summary - 1 | ADMISSION DIAGNOSES:,1. Menometrorrhagia.,2. Dysmenorrhea.,3. Small uterine fibroids.,DISCHARGE DIAGNOSES:,1. Menorrhagia.,2. Dysmenorrhea.,3. Small uterine fibroids.,OPERATION PERFORMED: ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL: ,The patient is a 42 year-old white female, gravida 3, para 2, with... | discharge summary, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids, |
3,915 | Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip. | Discharge Summary | Hemiarthroplasty - Discharge Summary | ADMISSION DIAGNOSES: ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED: ,Hemiarthroplasty, righ... | discharge summary, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip, |
3,916 | Decreased ability to perform daily living activity secondary to recent right hip surgery. | Discharge Summary | Hip Surgery - Discharge Summar | CHIEF COMPLAINT:, Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoper... | null |
3,917 | Intrauterine pregnancy at term with previous cesarean. Desired sterilization. Status post repeat low transverse cesarean and bilateral tubal ligation. | Discharge Summary | Intrauterine Pregnancy - Discharge Summary | ADMITTING DIAGNOSIS:, Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1. Intrauterine pregnancy at term with previous cesarean.,2. Desired sterilization.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , Th... | discharge summary, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy, |
3,918 | GI bleed. Upper gastrointestinal bleed. CBC revealed microcytic anemia. | Discharge Summary | GI Bleed - Discharge Summary | CHIEF COMPLAINT:, GI bleed.,HISTORY OF PRESENT ILLNESS:, The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The pa... | null |
3,919 | The patient underwent a total vaginal hysterectomy. | Discharge Summary | Hysterectomy - Discharge Summary | ADMISSION DIAGNOSES:,1. Menorrhagia.,2. Uterus enlargement.,3. Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and in... | discharge summary, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy, |
3,920 | Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease. | Discharge Summary | Hypothermia - Discharge Summary | DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:... | discharge summary, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures |
3,921 | Patient discharged after laparoscopic Roux-en-Y gastric bypass. | Discharge Summary | Gastric Bypass Summary | FINAL DIAGNOSES,1. Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. ,2. Hypertension. ,3. Obstructive sleep apnea, on CPAP.,OPERATION AND PROCEDURE: , Laparoscopic Roux-en-Y gastric bypass.,BRIEF HOSPITAL COURSE SUMMARY: ,This is a 30-year-old male, who presented recently to the Bariatric Center f... | discharge summary, medifast, laparoscopic roux-en-y gastric bypass, roux-en-y, bariatric clear liquids, gastric bypass, laparoscopic, gastric, bariatric, bypass, |
3,922 | Acute gastroenteritis, resolved. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology. | Discharge Summary | Gastroenteritis - Discharge Summary | ADMITTING DIAGNOSES,1. Acute gastroenteritis.,2. Nausea.,3. Vomiting.,4. Diarrhea.,5. Gastrointestinal bleed.,6. Dehydration.,DISCHARGE DIAGNOSES,1. Acute gastroenteritis, resolved.,2. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This pat... | discharge summary, nausea, vomiting, diarrhea, gastrointestinal bleed, mesentery, hemoglobin, hematocrit, gastrointestinal, periumbilical, gastroenteritis, hemorrhoids |
3,923 | Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency. | Discharge Summary | Goldenhar Syndrome - Discharge Summary | ADMITTING DIAGNOSES,1. Vomiting, probably secondary to gastroenteritis.,2. Goldenhar syndrome.,3. Severe gastroesophageal reflux.,4. Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1. Gastroenteritis versus bowel obstruction.,2. Gastroesophageal reflux.,3. Goldenhar syndrome.,4. Anemia,... | null |
3,924 | Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed. | Discharge Summary | Gastrointestinal Bleed - Discharge Summary | DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:, Colonoscopy.,FINDINGS:, Poor prep with friable internal hemorrhoids, but no gross... | discharge summary, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep |
3,925 | Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection. | Discharge Summary | Discharge Summary - Urology & Nephrology | ADMITTING DIAGNOSES:, Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureterosc... | null |
3,926 | Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home. | Discharge Summary | Falls - Discharge Summary | CHIEF COMPLAINT:, Falls at home.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They... | null |
3,927 | A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss. | Discharge Summary | Ectopic Pregnancy - Discharge Summary | HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possibl... | discharge summary, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic, |
3,928 | Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis. | Discharge Summary | Discharge Summary - Urology | ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was ... | discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, urology, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, ... |
3,929 | 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. | Discharge Summary | 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 |
3,930 | This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection. | Discharge Summary | ESRD - Discharge Summary | ADMISSION DIAGNOSIS:, End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:, Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis si... | null |
3,931 | A 3-year-old abrupt onset of cough and increased work of breathing. | Discharge Summary | Discharge Summary - Respiratory Distress | ADMITTING DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,DISCHARGE DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,3. Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who ... | null |
3,932 | The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations. | Discharge Summary | Discharge Summary - Peripheral vascular disease | ADMITTING DIAGNOSIS:, A nonhealing right below-knee amputation.,DISCHARGE DIAGNOSIS:, A nonhealing right below-knee amputation.,SECONDARY DIAGNOSES:, Include:,1. Peripheral vascular disease, bilateral carotid artery stenosis status post bilateral carotid endarterectomies.,2. Peripheral vascular disease status post... | null |
3,933 | The patient was admitted after undergoing a drawn out process with a small bowel obstruction. | Discharge Summary | Discharge Summary - Respiratory Failure | DISCHARGE DIAGNOSIS:,1. Respiratory failure improved.,2. Hypotension resolved.,3. Anemia of chronic disease stable.,4. Anasarca improving.,5. Protein malnourishment improving.,6. End-stage liver disease.,HISTORY AND HOSPITAL COURSE: ,The patient was admitted after undergoing a drawn out process with a small bowe... | discharge summary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge, |
3,934 | Aftercare of multiple trauma from an motor vehicle accident. | Discharge Summary | Discharge Summary - Multiple Trauma | ADMITTING DIAGNOSIS:, Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1. Aftercare following surgery for injury and trauma.,2. Decubitus ulcer, lower back.,3. Alcohol induced persisting dementia.,4. Anemia.,5. Hypokalemia.,6. Aftercare healing traumatic fracture of the lower arm... | null |
3,935 | Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy. | Discharge Summary | Discharge Summary - Nephrology | ADMITTING DIAGNOSES:, Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:, Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1. Chronic obstructive pulmonary disease.,2. Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HIS... | discharge summary, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge, |
3,936 | Diffuse Large B-cell Lymphoma | Discharge Summary | Discharge Summary - Lymphoma | DISCHARGE DIAGNOSES:,1. Central nervous system lymphoma.,2. Gram-negative bacteremia.,3. Pancytopenia.,4. Hypertension.,5. Perianal rash.,6. Diabetes mellitus.,7. Hypoxia.,8. Seizure prophylaxis.,9. Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle five high-dose methotrexate.,2. Rituxan weekl... | null |
3,937 | Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis. | Discharge Summary | Discharge Summary - Mesothelioma - 1 | PRINCIPAL DIAGNOSIS:, Mesothelioma.,SECONDARY DIAGNOSES:, Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2. On August 20, 2007, thoracentes... | null |
3,938 | Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators. | Discharge Summary | Discharge Summary - COPD | PROCEDURES:,1. Chest x-ray on admission, no acute finding, no interval change.,2. CT angiography, negative for pulmonary arterial embolism.,3. Nuclear myocardial perfusion scan, abnormal. Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1. Chronic obstructive pulmonary di... | null |
3,939 | The patient is being discharged for continued hemodialysis and rehab. | Discharge Summary | Discharge Summary - Hemodialysis | DISCHARGE DIAGNOSES:,1. End-stage renal disease, on hemodialysis.,2. History of T9 vertebral fracture.,3. Diskitis.,4. Thrombocytopenia.,5. Congestive heart failure with ejection fraction of approximately 30%.,6. Diabetes, type 2.,7. Protein malnourishment.,8. History of anemia.,HISTORY AND HOSPITAL COURSE: , T... | discharge summary, end-stage renal disease, thrombocytopenia, anemia, hospitalization, hemodialysis and rehab, hemodialysis |
3,940 | Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation. | Discharge Summary | Discharge Summary - Migraine | ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:, Migraine with aura.,SECONDARY DIAGNOSES:,1. Bipolar disorder.,2. Iron deficiency anemia.,3. Anxiety disorder.,4. History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1. CT of the head with and without contrast, which was ne... | null |
3,941 | Trauma/ATV accident resulting in left open humerus fracture. | Discharge Summary | Discharge Summary - ATV Accident | ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:, Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:, None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008. ... | discharge summary, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture, orthopedic, |
3,942 | Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. | Discharge Summary | Discharge Summary - Gastric Bypass | ADMISSION DIAGNOSIS:, Morbid obesity. BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity. BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years. She has made m... | discharge summary, laparoscopic gastric bypass, gastric bypass, morbid obesity, liquid diet, bmi, discharge, |
3,943 | A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma. | Discharge Summary | Discharge Summary - Mesothelioma | PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1. Flexible bronchoscopy.,2. Mediastinoscopy.,3. Right thoracotomy.,4. Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1. Radiation Oncology.,2. Pulmonary Medicin... | discharge summary, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology, |
3,944 | A 47-year-old female with a posttraumatic AV in the right femoral head. | Discharge Summary | Discharge Summary - Hip Surgery | ADMITTING DIAGNOSIS:, Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:, Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1. Opioid use.,2. Right hip surgery.,3. Appendectomy.,4. Gastroesophageal reflux disease.,5. Hepatitis diagnosed by liver biopsy.,6. Blood tra... | null |
3,945 | Patient with fever of unknown origin. | Discharge Summary | Discharge Summary - 7 | REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week. The patient has also been on high-dose prednisone for an urticarial rash. The patient was admitted because of persistent high fevers without ... | discharge summary, fever of unknown origin, blood cultures, transbronchial biopsies, infection, cmv, admission, illness, interstitial, fever, serologies, chest, nondiagnostic, methotrexate |
3,946 | Patient with complaint of symptomatic cholelithiasis. | Discharge Summary | Discharge Summary - Cholelithiasis | ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:, Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:, None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to th... | discharge summary, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge, |
3,947 | A white female with a history of fevers. | Discharge Summary | Discharge Summary - 8 | DISCHARGE DIAGNOSES:,1. Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007... | discharge summary, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge |
3,948 | a pleasant 62-year-old male with cerebral palsy | Discharge Summary | Discharge Summary - Cerebral Palsy | DISCHARGE DIAGNOSES:,1. Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2. Prostatic hypertrophy with bladder outlet obstruction.,3. Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazoli... | discharge summary, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge, |
3,949 | A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. | Discharge Summary | Discharge Summary - 9 | DISCHARGE DIAGNOSIS:,1. Epigastric pain. Questionable gastritis, questionable underlying myocardial ischemia.,2. Congestive heart failure exacerbation.,3. Small pericardial effusion with no tamponade.,4. Hypothyroidism.,5. Questionable subacute infarct versus neoplasm in the pons.,6. History of coronary artery d... | null |
3,950 | A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. | Discharge Summary | Discharge Summary - 6 | DISCHARGE DATE: MM/DD/YYYY,HISTORY OF PRESENT ILLNESS: Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. He underwent a resection there. He was to be admitted to the Day Hospital for cystectomy. He ... | discharge summary, coronary artery disease, heart catheterization, artery disease, bare metal, metal stents, artery intervention, bladder cancer, coronary artery, veteran, surgery, cardiac, inducible, catheterization, ischemia, cancer, urology, stenosed, bladder, heart, artery, coronary, |
3,951 | The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out. | Discharge Summary | Discharge Summary - 18 | ADMISSION DIAGNOSES:,1. Atypical chest pain.,2. Nausea.,3. Vomiting.,4. Diabetes.,5. Hypokalemia.,6. Diarrhea.,7. Panic and depression.,8. Hypertension.,DISCHARGE DIAGNOSES:,1. Serotonin syndrome secondary to high doses of Prozac.,2. Atypical chest pain with myocardial infarction ruled out.,3. Diabetes melli... | null |
3,952 | Patient with increased shortness of breath of one day duration. | Discharge Summary | Discharge Summary - 3 | DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF... | discharge summary, chronic obstructive pulmonary disease, hypercapnic respiratory failure, atrial fibrillation, chronic atrial fibrillation, increased shortness of breath, shortness of breath, increased shortness, coumadin, atrial, |
3,953 | Patient with complaints of shortness of breath and was found to have acute COPD exacerbation. | Discharge Summary | Discharge Summary - 2 | ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyro... | null |
3,954 | The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection. | Discharge Summary | Discharge Summary - 19 | PRIMARY DISCHARGE DIAGNOSES:,1. Urinary tract infection.,2. Gastroenteritis with nausea and vomiting.,3. Upper gastrointestinal bleed likely secondary to gastritis.,4. Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1. Hypertension.,2. Gastroesophageal reflux disease.,3. Chronic atrial fibrillation... | null |
3,955 | The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved. | Discharge Summary | Discharge Summary - 17 | FINAL DIAGNOSIS/REASON FOR ADMISSION:,1. Acute right lobar pneumonia.,2. Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3. Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4. Elevated liver function tests, etiology undetermined.,5. The patient has a history of moderate-to... | discharge summary, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures |
3,956 | A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity. | Discharge Summary | Discharge Summary - 5 | DATE OF ADMISSION:, MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:, X Y, M.D.,ADMITTING DIAGNOSES:,1. Ewing sarcoma.,2. Anemia.,3. Hypertension.,4. Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION: ,Cycle seven Ifosfamide, mesna, and VP-16 chemoth... | discharge summary, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma, |
3,957 | Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary. | Discharge Summary | Discharge Summary - 4 | DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS: , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surger... | null |
3,958 | A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity. | Discharge Summary | Discharge Summary - 12 | CURRENT HISTORY:, A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI. She also has renal insufficiency and digitalis toxicity. She is admitted for further treatment.,Past medical history, social history, family history, physical examination c... | null |
3,959 | Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. | Discharge Summary | Discharge Summary - 15 | FINAL DIAGNOSES:,1. Gastroenteritis.,2. Autism.,DIET ON DISCHARGE:, Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESE... | discharge summary, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall |
3,960 | Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis. | Discharge Summary | Discharge Summary - 11 | ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF... | discharge summary, medifast, hyperglycemia, laparoscopic cholecystectomy, medifast diet, cholecystitis, cholelithiasis, diabetes mellitus, hypertension, morbid obesity, obstructive sleep apnea, sleep apnea, diabetes, |
3,961 | Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome. | Discharge Summary | Discharge Summary - 13 | ADMITTING DIAGNOSES:,1. Bradycardia.,2. Dizziness.,3. Diabetes.,4. Hypertension.,5. Abdominal pain.,DISCHARGE DIAGNOSIS:, Sick sinus syndrome. The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patien... | null |
3,962 | Cardiac arrest, severe congestive heart failure, acute on chronic respiratory failure, osteoporosis, and depression. | Discharge Summary | Death Summary - 2 | FINAL DIAGNOSES:,1. Cardiac arrest.,2. Severe congestive heart failure.,3. Acute on chronic respiratory failure.,4. Osteoporosis.,5. Depression.,HISTORY OF PRESENT ILLNESS: , This 92-year-old lady with history of depression and chronic low back pain, osteoporosis, and congestive heart failure, was diagnosed having... | discharge summary, bradycardiac, hypertension, hospice, congestive heart failure, cardiac arrest, respiratory failure, |
3,963 | The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. | Discharge Summary | Discharge Summary - 14 | HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained b... | discharge summary, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission, |
3,964 | Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis. | Discharge Summary | Death Summary - 1 | DISCHARGE DIAGNOSES:,1. Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,2. Respiratory failure secondary to above.,3. Likely postobstructive pneumonia.,4. Gastrointestinal bleed.,5. Thrombocytopenia.,6. Acute renal fail... | discharge summary, dnr, pronounced expired, extubated, death summary, lung carcinoma, pleural effusion, |
3,965 | Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever. | Discharge Summary | Discharge Summary - 16 | ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week... | discharge summary, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis, |
3,966 | Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. | Discharge Summary | Discharge Summary - 10 | ADMITTING DIAGNOSES:, Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:, Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-o... | discharge summary, |
3,967 | Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease. | Discharge Summary | CVA - Discharge Summary | DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the lef... | discharge summary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident |
3,968 | Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia. | Discharge Summary | Discharge Summary - 1 | DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/200... | null |
3,969 | Death summary of an 80-year-old patient with a history of COPD. | Discharge Summary | Death Summary | CAUSE OF DEATH:,1. Acute respiratory failure.,2. Chronic obstructive pulmonary disease exacerbation.,SECONDARY DIAGNOSES:,1. Acute respiratory failure, probably worsened by aspiration.,2. Acute on chronic renal failure.,3. Non-Q wave myocardial infarction.,4. Bilateral lung masses.,5. Occlusive carotid disease.,... | discharge summary, myocardial infarction, intensive care unit, acute respiratory failure, death summary, atrial fibrillation, renal function, telemetry floor, respiratory failure, death, chronic, exacerbation, infarction, respiratory |
3,970 | Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. | Discharge Summary | Cognitive Linguistic Impairment - Discharge | DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initia... | discharge summary, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic, |
3,971 | Patient had some cold symptoms, was treated as bronchitis with antibiotics. | Discharge Summary | Discharge Summary | DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY... | discharge summary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, |
3,972 | Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section. | Discharge Summary | Cholestasis Of Pregnancy | FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On ... | discharge summary, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis |
3,973 | Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction. | Discharge Summary | 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... | discharge summary, laparoscopy, common bile duct exploration, laparoscopic cholecystectomy, bile duct, choledocholithiasis, cholecystectomy, cholecystitis, laparoscopic, hernia |
3,974 | A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. | Discharge Summary | COPD - Discharge Summary | HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was adm... | discharge summary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd, |
3,975 | Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus. | Discharge Summary | D&C - Discharge Summary | ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,OPERATIONS PERFORMED:,1. Hysteroscopy.,2. Dilatation and curettage (D&C).,3.... | discharge summary, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid, |
3,976 | Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis. | Discharge Summary | COPD & Bronchitis - Discharge Summary | DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypot... | discharge summary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis, |
3,977 | Congestive heart failure (CHF) with left pleural effusion. Anemia of chronic disease. | Discharge Summary | CHF & Pleural Effusion - Discharge Summary | DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1. Congestive heart failure (CHF) with pleural effusion.,2. Hypertension.,3. Prostate cancer.,4. Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted to the emergency room b... | discharge summary, prostate cancer, anemia of chronic disease, congestive heart failure, pleural effusion, thoracentesis, chf, anemia |
3,978 | Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh. | Discharge Summary | Chronic Abscesses - Discharge Summary | DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft t... | discharge summary, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics, |
3,979 | A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure. | Discharge Summary | Cardio/Pulmo Discharge Summary | ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5... | discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infar... |
3,980 | Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. | Discharge Summary | Cellulitis - Discharge Summary | DISCHARGE DIAGNOSIS: ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1. Chronic pain.,2. Tobacco use.,3. History of hepatitis C.,REASON FOR ADMISSION:, The patient is a 52-year-old male who has had a very complex cou... | discharge summary, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis, |
3,981 | Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome. | Discharge Summary | Back & Leg Pain - Discharge Summary | ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:, Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morp... | discharge summary, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg |
3,982 | A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina. | Discharge Summary | Chest Pain & Respiratory Insufficiency | We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have ni... | discharge summary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic |
3,983 | Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable. | Discharge Summary | Bronchiolitis - Discharge Summary | DIAGNOSES:,1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always bee... | discharge summary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs, |
3,984 | Discharge summary of a patient with a BRCA-2 mutation. | Discharge Summary | BRCA-2 mutation | DISCHARGE DIAGNOSES:, BRCA-2 mutation. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION: ,The chest was clear. The abdomen was nontender. Pelvic examination shows no mas... | discharge summary, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer, |
3,985 | Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. | Discharge Summary | Back Pain - Discharge Summary | CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years,... | null |
3,986 | Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning. | Discharge Summary | Cardiac Transfer Summary | REASON FOR TRANSFER:, Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1. Coronary artery disease.,2. Chest pain.,3. History of diabetes.,4. History of hypertension.,5. History of obesity.,6. A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7. Deconditioning.,CONSULTATIONS: , C... | null |
3,987 | Counting calorie points, exercising pretty regularly, seems to be doing well | Diets and Nutritions | Dietary Consult - 4 | SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. Th... | diets and nutritions, overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly |
3,988 | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | Diets and Nutritions | Dietary Consult - Weight Reduction | SUBJECTIVE:, This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendation... | diets and nutritions, hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food |
3,989 | Dietary consultation for gestational diabetes. | Diets and Nutritions | Dietary Consult - Gestational Diabetes | SUBJECTIVE:, This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with ... | diets and nutritions, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning |
3,990 | Dietary consultation for diabetes during pregnancy. | Diets and Nutritions | Dietary Consult - Diabetes - 1 | SUBJECTIVE:, This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back... | diets and nutritions, diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks |
3,991 | Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6. | Discharge Summary | Anterior Cervical Discectomy & Fusion - Discharge Summary | FINAL DIAGNOSES:,1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2. Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a... | discharge summary, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy, |
3,992 | Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome | Diets and Nutritions | Dietary Consult - Hyperlipidemia | SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was... | diets and nutritions, hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight |
3,993 | Elevated cholesterol and is on medication to lower it. | Diets and Nutritions | Dietary Consult - 1 | SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has sta... | diets and nutritions, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol |
3,994 | Incision and drainage, first metatarsal head, left foot with culture and sensitivity. | Discharge Summary | Abscess with Cellulitis - Discharge Summary | ADMITTING DIAGNOSIS:, Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:, Status post I&D, left foot.,PROCEDURES:, Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:, The patient presented to Dr. X's office on 06/14/07 complaining of a painful lef... | discharge summary, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage, |
3,995 | Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983. | Diets and Nutritions | Dietary Consult - Diabetes - 2 | SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at ... | diets and nutritions, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes, |
3,996 | The patient is brought in by an assistant with some of his food diary sheets. | Diets and Nutritions | Dietary Consult - 3 | SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went o... | diets and nutritions, weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food |
3,997 | The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. | Diets and Nutritions | Dietary Consult - 2 | SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food d... | diets and nutritions, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food |
3,998 | Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis. | Dermatology | Scalp Mole Skin Biopsy | PROCEDURE: , Skin biopsy, scalp mole.,INDICATION: ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1. K-Y jelly.,2. Betadine prep locally.,3. A 1% lidocaine with epinephrine local instilled.,4. A 3 mm punch ... | dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma, |
3,999 | Punch biopsy of right upper chest skin lesion. | Dermatology | Punch Biopsy - 1 | PROCEDURE:, Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, The area around the lesion was anesthetized after she gave consent for her procedure. Punch biopsy including some portion of lesion and normal tissue was performed. Hemos... | dermatology, punch biopsy, skin lesion, |
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