Unnamed: 0 int64 0 5k | description stringlengths 1 492 | medical_specialty stringlengths 8 30 | sample_name stringlengths 5 69 | transcription stringlengths 11 18.4k ⌀ | keywords stringlengths 1 916 ⌀ |
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4,000 | Dietary consultation for carbohydrate counting for type I diabetes. | Diets and Nutritions | Carbohydrate Counting | SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood ... | diets and nutritions, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin |
4,001 | Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak. | Dermatology | Poison Ivy - SOAP | SUBJECTIVE:, He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackma... | dermatology, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison |
4,002 | The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. | Dermatology | Skin Biopsy | PROCEDURE: ,The site was cleaned with antiseptic. A local anesthetic (2% lidocaine) was given at each site. A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee. The site was then checked for bleeding. Once hemostasis was achieved, a local antibiotic was placed and the site was bandage... | dermatology, antiseptic, local anesthetic, hemostasis, punch biopsy, band-aid, skin biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medica... |
4,003 | Mohs Micrographic Surgery for basal cell CA at medial right inferior helix. | Dermatology | Mohs Micrographic Surgery - 2 | PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: ,Medial right inferior helix.,PREOP SIZE:, 1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESC... | dermatology, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage, |
4,004 | Mohs Micrographic Surgery for basal cell CA at mid parietal scalp. | Dermatology | Mohs Micrographic Surgery - 1 | PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:, 1.5 x 2.9 cm,POSTOP SIZE:, 2.7 x 2.9 cm,INDICATION:, Poorly defined borders.,COMPLICATIONS:, None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:, Simple Linear Closure.,DESCRIPTION OF PROCED... | dermatology, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage, |
4,005 | Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. | Dermatology | Wasp Sting - SOAP | SUBJECTIVE:, He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he w... | dermatology, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp, |
4,006 | Worrisome skin lesion. A punch biopsy of the worrisome skin lesion was obtained. Lesion was removed. | Dermatology | Punch Biopsy - 2 | PREOPERATIVE DIAGNOSIS:, Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:, Worrisome skin lesion, left hand.,PROCEDURE:, The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual ste... | dermatology, skin lesion, squamous cell carcinoma, punch biopsy, |
4,007 | Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. | Dermatology | 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 |
4,008 | Patient comes in for initial evaluation of a hyperesthesia on his right abdomen. | Dermatology | Hyperesthesia | SUBJECTIVE:, This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. N... | dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation |
4,009 | Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures | Dermatology | Excision - Actinic Neoplasm | PREOPERATIVE DIAGNOSES:,1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5... | null |
4,010 | Incision and drainage (I&D) of buttock abscess. | Dermatology | I&D - Buttock Abscess | PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:, Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE: ,Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diamet... | dermatology, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage |
4,011 | A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back. | Dermatology | Epidermal Autograft | PREOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1. Epidermal autograft on Integra to the... | dermatology, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft, |
4,012 | 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. | Dermatology | 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... | dermatology, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, |
4,013 | The patient presents for a followup for history of erythema nodosum. | Dermatology | Erythema Nodosum - Consult | REASON FOR VISIT:, The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specif... | null |
4,014 | Evaluation and recommendations regarding facial rhytids. | Dermatology | Facial Rhytids | HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial f... | dermatology, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These trans... |
4,015 | Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm. | Dermatology | Excision - Skin Neoplasm | PREOPERATIVE DIAGNOSES:,1. Enlarging nevus of the left upper cheek.,2. Enlarging nevus 0.5 x 1 cm, left lower cheek.,3. Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1. Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2. Excision of the left lower cheek ... | dermatology, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek |
4,016 | Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm. | Dermatology | Excision - Keratotic Neoplasm | PREOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1. Enlarging dark keratoti... | dermatology, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision, |
4,017 | Hand dermatitis. | Dermatology | Dermatitis - SOAP | SUBJECTIVE:, This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and ... | dermatology, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis |
4,018 | Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, | Dermatology | Biopsy - Actinic Keratosis | PREOPERATIVE DIAGNOSES: ,1. Left chest actinic keratosis, 2 cm.,2. Left medial chest actinic keratosis, 1 cm.,3. Left shoulder actinic keratosis, 1 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left chest actinic keratosis, 2 cm.,2. Left medial chest actinic keratosis, 1 cm.,3. Left shoulder actinic keratosis, 1 cm.,TITLE O... | dermatology, two-layer plastic closure, one-layer plastic closure, skin nevus, actinic keratosis, plastic closures, keratosis, actinic, biopsy, forceps, layer, closures, chest |
4,019 | Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides. | Dermatology | Cheek-Neck Facelift | PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-yea... | dermatology, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck, |
4,020 | First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. | Dermatology | Burn - Consult | CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents wi... | dermatology, burn, workers' compensation industrial injury, workers' compensation, degree |
4,021 | 1+ year, black female for initial evaluation of a lifelong history of atopic eczema. | Dermatology | Atopic Eczema | SUBJECTIVE:, This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working no... | dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel, |
4,022 | 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.. | Dentistry | 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... | dentistry, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, |
4,023 | Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata. | Dermatology | Condyloma Cauterization | PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:, Cauterization of peri and intra-anal condylomas.,ANESTHESIA: ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BL... | dermatology, intra-anal, perianal, acuminata, cauterization, condyloma, anal, |
4,024 | Left buttock abscess, status post incision and drainage. Recommended some local wound care | Dermatology | Buttock Abscess | CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The... | dermatology, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess, |
4,025 | Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess. | Dentistry | Teeth Extraction & I&D - 1 | PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:, Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:, Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: ... | dentistry, yankauer suction, orogastric tube, carious teeth, penrose drain, forceps extraction, dental abscess, incision, elevator, mandibular, dental, abscess, teeth, intraoral, extraction, drainage, |
4,026 | Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19. | Dentistry | Teeth Extraction & I&D | PREOPERATIVE DIAGNOSES,1. Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2. Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1. Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2. Left mandibular vestibular abscess.,PROCEDURE,1. Extraction of teeth #2. #5, #12, #15, #18, #19, #31.,2. Incision an... | dentistry, mandibular, vestibular, abscess, throat pack, purulent material, forceps extraction, nasogastric tube, carious teeth, incision, teeth, nasogastric, carious, extraction |
4,027 | Acne with folliculitis. | Dermatology | Acne - SOAP | SUBJECTIVE:, The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flarin... | dermatology, acne with folliculitis, tazorac cream, acne, tazorac, cream, folliculitis, |
4,028 | Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.
| Dentistry | Teeth Extraction | PREOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Im... | dentistry, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth, |
4,029 | Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T. | Dentistry | Teeth Extraction & I&D - 2 | PREOPERATIVE DIAGNOSIS:, Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:, General, oral endotracheal tube.,COMPLICATIONS: , ... | dentistry, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess |
4,030 | Full-mouth extraction of teeth and alveoloplasty in all four quadrants. | Dentistry | Teeth (full-mouth) Extraction | PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:, Nasotracheal general anesthesia.,IV FLUIDS:, A 7... | null |
4,031 | A simple note on Acne Vulgaris. | Dermatology | Acne Vulgaris | ACNE VULGARIS,, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life. The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.,SIGNS AND SYMPTOMS:,* Bla... | null |
4,032 | Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris | Dermatology | Acne Vulgaris - H&P | CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of conditi... | |
4,033 | Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899. | Dentistry | ORIF - Mandible Fracture | PREOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:, Open reduction, internal fixation (ORIF) of bilateral mandible fra... | dentistry, mandible, endotracheal, leibinger, pacu, oral maxillary facial surgery, maxillofacial, buckle, round bur, lidocaine with epinephrine, surgical steel wire, bilateral mandible fractures, mandible fracture, orif, symphysis, fracture, |
4,034 | Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. | Dentistry | ORIF Mandibular Fracture & Dental Implant Removal | PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular frac... | dentistry, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant, |
4,035 | Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess. | Dentistry | Odontogenic Abscess I&D | PREOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA: ... | dentistry, odontogenic, facial cellulitis, incision and drainage, fna, buccogingival, odontogenic abscess, abscess, drainage, i&d, cellulitis, |
4,036 | Letter on evaluation regarding extraction of mandibular left second molar tooth #18. | Dentistry | Letter - Dentistry | XYZ, S.,RE: ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18. This previously root-canaled tooth, now failed, is scheduled for removal. As per your request, I agree that placem... | dentistry, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth |
4,037 | Autologous iliac crest bone graft to maxilla and mandible under general anesthetic. Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction. | Dentistry | Iliac Crest Bone Graft - Maxilla & Mandible | PREOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac cre... | dentistry, autologous iliac crest bone graft, to, mandible, mandibular atrophy, maxillary atrophy, facial deformity, masticatory dysfunction, iliac crest bone graft, mental foramina, iliac crest, bone, autologous, maxillary, mandibular, maxilla |
4,038 | Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis. | Dermatology | Biopsy - Skin Nevus | PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. ... | dermatology, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps, |
4,039 | Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210. | Dentistry | Surgical Removal of Teeth | PREOPERATIVE DIAGNOSIS:, Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth. ICD9 Code: 528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of th... | dentistry, cultures, buccal, teeth, canine, pacu, teeth extractions, oromaxillary facial, facial surgery, buccal space, throat pack, buccal mucosa, surgical removal, canine's base, necrotic teeth, cpt code, infection, oral, surgery, mucosa, anesthesia, facial, pus, toothache, |
4,040 | Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. | Dentistry | 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... | dentistry, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, |
4,041 | Full mouth dental rehabilitation in the operative room under general anesthesia. | Dentistry | Full Mouth Dental Rehabilitation - 2 | OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,... | dentistry, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth, |
4,042 | Incision and drainage of right buccal space abscess and teeth extraction. | Dentistry | I&D - Buccal Space Abscess | PREOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1. Incision and drainage of right buccal space abscess.,2. Extraction of teet... | dentistry, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal, |
4,043 | Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures. | Dentistry | Mandible Fractures Closed Reduction | HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mand... | dentistry, closed reduction of mandible fractures, erich arch bars, elastic fixation, throat pack, arch bars, arch, erich, mandible, fractures |
4,044 | Full mouth dental rehabilitation in the operating room under general anesthesia. | Dentistry | Full Mouth Dental Rehabilitation - 1 | OPERATION PERFORMED:, Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,POSTOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,3. Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal... | |
4,045 | Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. | Dentistry | Dental Restoration | PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:, Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY: ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting. He was referred to me for that reason to... | dentistry, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries, |
4,046 | Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17. | Dentistry | Extraoral I&D | PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of... | dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth, |
4,047 | Significant pain in left lower jaw. | Dentistry | 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 |
4,048 | Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth. | Dentistry | Carious Teeth Extraction | PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 1... | dentistry, intraoral procedure, partial bony impacted tooth, teeth extraction, forceps extraction, periodontal disease, carious teeth, periodontal, carious |
4,049 | Dental prophylaxis under general anesthesia. | Dentistry | Dental Prophylaxis | OPERATION PERFORMED: ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1. Impacted wisdom teeth.,2. Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1. Impacted wisdom teeth.,2. Moderate gingivitis.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,Minimal.,DURATION OF SURGERY: ,One hour 17 minutes.... | dentistry, dental prophylaxis, impacted wisdom teeth, gingivitis, wisdom teeth, moderate gingivitis, dental rehabilitation, throat pack, digital radiographs, restorative dentistry, impacted, anesthesia, restorative, wisdom, oral, prophylaxis, teeth, dental, |
4,050 | Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17. | Dentistry | Bone Impacted Tooth Removal | PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:, Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA: ... | dentistry, dentigerous, wisdom tooth, extraction, bone impacted tooth, nasal endotracheal, dentigerous cyst, cyst, intubation, osteotomy, mandible, |
4,051 | Dental restorations and extractions. Dental caries. He has had multiple severe carious lesions that warrant multiple extractions at this time. | Dentistry | Dental Restorations & Extractions | PREOPERATIVE DIAGNOSIS:, Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several is... | dentistry, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries |
4,052 | 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. | Dentistry | 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... | dentistry, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental, |
4,053 | Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose. | Cosmetic / Plastic Surgery | Rhinoplasty | PREOPERATIVE DIAGNOSES:,1. Nasal obstruction secondary to deviated nasal septum.,2. Bilateral turbinate hypertrophy.,PROCEDURE:, Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: ,The patient is a 26-yea... | cosmetic / plastic surgery, nasal obstruction, cosmetic, dorsal hump, endotracheal tube, hemitransfixion incision, hypertrophy, intercartilaginous, intercartilaginous incision, nasal septum, nasal tip, septomucoperichondrial, submucoperichondrial, subperiosteal, turbinate, vomerine, spur, nasal septal, nasal, rhinoplas... |
4,054 | Bilateral open mandible fracture, open left angle and open symphysis fracture. Closed reduction of mandible fracture with MMF. | Dentistry | Closed Reduction - Mandible Fracture | PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE: ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endot... | dentistry, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible, |
4,055 | Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen. | Cosmetic / Plastic Surgery | Rhytidectomy & Blepharoplasty | PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous ... | cosmetic / plastic surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quad... |
4,056 | Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy | Cosmetic / Plastic Surgery | Nipple Reconstruction | PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a fu... | cosmetic / plastic surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, a... |
4,057 | Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold. | Cosmetic / Plastic Surgery | Perlane & Restylane Injection | PREOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,POSTOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,TITLE OF PROCEDURES: ,1. Perlane injection for the nasolabial fold.,2. Restylane injection for the glabellar fold.,ANESTHESIA: ,Topical with Lasercai... | cosmetic / plastic surgery, lasercaine, nasolabial mesiolabial fold, mid glabellar fold, perlane injection, restylane injection, nasolabial fold, mesiolabial fold, glabellar fold, injection, perlane, nasolabial, glabellar, restylane |
4,058 | Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad. | Cosmetic / Plastic Surgery | Midface Lift & Blepharoplasty | PREOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,PROCEDURES:,1. Endoscopic subperiosteal midface lift using the endotine midface suspension d... | cosmetic / plastic surgery, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal, |
4,059 | Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg. | Cosmetic / Plastic Surgery | Skin Graft | DIAGNOSIS:, Stasis ulcers of the lower extremities,OPERATION:, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:, This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the o... | cosmetic / plastic surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg, |
4,060 | Bilateral transaxillary subpectoral mammoplasty with saline-filled implants. | Cosmetic / Plastic Surgery | Mammoplasty - 4 | DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:, Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:, General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and ... | cosmetic / plastic surgery, bilateral transaxillary subpectoral mammoplasty, saline filled implants, subpectoral mammoplasty, mammoplasty, transaxillary, subpectoral, implants, breasts, saline, anesthesia |
4,061 | Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation. | Cosmetic / Plastic Surgery | Nasolabial Fold Elevation | PREOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1. Left midface elevation with nasolabial fold elevation.,2. Left nasolabial fold z-plasty and right symmet... | null |
4,062 | Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping. | Cosmetic / Plastic Surgery | Mammoplasty - 2 | PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1. Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2. TCA peel to two lesions of the face and v... | cosmetic / plastic surgery, breast hypoplasia, monocryl, pacu, tca, tca peel, ted hose, augmentation mammoplasty, breast implant, melasma, poor wound healing, popliteal fossa area, prepped and draped, silicone, varicose vein, vein stripping, mastisol steri strips, steri strips, circumareolar incisions, mammary gel, var... |
4,063 | Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure. | Cosmetic / Plastic Surgery | Flap revision | PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.... | null |
4,064 | Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs. | Cosmetic / Plastic Surgery | Lipectomy - Abdomen/Thighs | PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:, Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:, General.,FINDINGS AND PROCEDURE:, With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks... | cosmetic / plastic surgery, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs, |
4,065 | Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty. | Cosmetic / Plastic Surgery | Hemangioma Debulking & Rhinoplasty | PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:, Hemangioma, nasal tip.,PROCEDURE PERFORMED: ,1. Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2. Rhinoplasty.,ESTIMATED BLOOD LOSS: ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columel... | cosmetic / plastic surgery, rhinoplasty approach, debulking of hemangioma, nasal domes, lower lateral cartilages, nasal tip, columella, hemangioma, debulking, cartilages, rhinoplasty, nasal, |
4,066 | Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
| Cosmetic / Plastic Surgery | Liposuction | PREOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,PROCEDURES:... | cosmetic / plastic surgery, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant, |
4,067 | Bilateral reduction mammoplasty for bilateral macromastia | Cosmetic / Plastic Surgery | Mammoplasty - 1 | PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. Right breast was slightly larger than ... | cosmetic / plastic surgery, macromastia, estimated blood loss, monocryl, steri-stripped, dermis, inferior breast, mammoplasty, neo-nipple, prepped and draped, ptotic breasts, recovery room in good condition, reduction mammoplasty, superior breast, upright position, bilateral macromastia, incision, superiorly, breasts |
4,068 | Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex. | Cosmetic / Plastic Surgery | Mammoplasty - 3 | PREOPERATIVE DIAGNOSES:, Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:, Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:, Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal ... | cosmetic / plastic surgery, bilateral mammary hypertrophy, duraprep, general endotracheal anesthesia, jackson-pratt drains, breast asymmetry, hypertrophy, inframammary folds, mammary, mammoplasty, nipple areolar complex, nipple-areolar complex, parenchymal, pedicle, prepped and draped, reduction mammoplasty, transposit... |
4,069 | Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies. | Cosmetic / Plastic Surgery | Lipectomy - Breast | PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient... | cosmetic / plastic surgery, breast ptosis, dermabond, mammary hypertrophy, monocryl, anesthesia, breast tissue, endotracheal anesthesia, lipectomy, mastopexies, mastopexy, nipple, nipple-areolar complex, suction assisted lipectomy, nipple areolar complex, lactated ringers, nipple areolar, areolar complex, epithelializa... |
4,070 | Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging. | Cosmetic / Plastic Surgery | Blepharoplasty - Quad | PREOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,... | cosmetic / plastic surgery, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty, |
4,071 | Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides. | Cosmetic / Plastic Surgery | Cheek-Neck Facelift | PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-yea... | cosmetic / plastic surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck, |
4,072 | Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy. | Cosmetic / Plastic Surgery | Browlift, Blepharoplasty, & Rhytidectomy | PREOPERATIVE DIAGNOSES:,1. Eyebrow ptosis.,2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. Cervical facial aging with submental lipodystrophy.,OPERATION:,1. Hairline biplanar temporal browlift.,2. Quadrilateral blepharoplasty with lateral canthopexy with arcus margi... | cosmetic / plastic surgery, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis... |
4,073 | A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back. | Cosmetic / Plastic Surgery | Epidermal Autograft | PREOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1. Epidermal autograft on Integra to the... | cosmetic / plastic surgery, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft, |
4,074 | Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery. | Cosmetic / Plastic Surgery | Capsulotomy & Flat Advancement, Left Breast | PREOPERATIVE DIAGNOSIS: , Breast assymetry, status post previous breast surgery.,POSTOPERATIVE DIAGNOSIS: ,Breast assymetry, status post previous breast surgery.,OPERATION: , Capsulotomy left breast, flat advancement V to Y left breast for correction lower pole defect.,ANESTHESIA:, LMA.,FINDINGS AND PROCEDURE: ,The ... | cosmetic / plastic surgery, capsulotomy, biosyn, breast, breast assymetry, kefzol, mentor-smooth, breast surgeries, flat advancement, inframammary fold, lower pole defect, mammary, mammary prosthesis, nipple, breast surgery, assymetry, inframammary, capsule |
4,075 | Hypomastia. Patient wants breast augmentation and liposuction of her abdomen, | Cosmetic / Plastic Surgery | Breast Augmentation Consult | REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 34-year-old white female who is a nurse in the operating room. She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her. She is very bright and well informed ab... | cosmetic / plastic surgery, breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast, |
4,076 | Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction. | Cosmetic / Plastic Surgery | Breast Reconstruction | REASON FOR CONSULTATION:, Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year. She brought this to the attention of her primary care doctor and ... | cosmetic / plastic surgery, breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi, |
4,077 | Blepharoplasty procedure | Cosmetic / Plastic Surgery | Blepharoplasty | BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised ... | cosmetic / plastic surgery, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: Thesetranscribed medical transcription sample reports and examples are p... |
4,078 | Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft. | Cosmetic / Plastic Surgery | Bilateral Orbital Frontozygomatic Craniotomy | PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2. Bone grafts.,3. Bilateral forehead reconstruction wit... | cosmetic / plastic surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead, |
4,079 | Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, p... | Cosmetic / Plastic Surgery | Closure of Amputation Wounds | PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1. Left abdominal flap 5 x 5 cm to left forearm.,2. Debridement of skin, subcutaneous tissue, muscle, and bone.,3. Closure of wounds, simple closure approximately 8 cm.,4. Placement of ... | cosmetic / plastic surgery, abdominal flap, debridement, skin, subcutaneous tissue, muscle, bone, closure of wounds, vac, vac negative, upper extremity, closure, wounds, flap, extremity, amputation |
4,080 | Belly button piercing for insertion of belly button ring. | Cosmetic / Plastic Surgery | Belly Button Piercing | PROCEDURE:, Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:, The patient was prepped after informed consent was given of risk of infection and foreign body reaction. The area was marked by the patient and then prepped. The area was injected with 2% Xylocaine 1:100,000 epinephrine... | cosmetic / plastic surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE |
4,081 | A well-child check with concern of some spitting up quite a bit. | Consult - History and Phy. | Well-Child Check - 5 | SUBJECTIVE:, The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit. Mom wants to make sure that this is normal. The patient is nursing well every two to three hours. She does have some spitting up on occasion. It has happened two or three ... | consult - history and phy., well-child check, denver ii, child check, growth, development, denver, cardiovascular, maternal, mother, spitting, father, child, check, asthma, family, mom, |
4,082 | Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury | Consult - History and Phy. | Worker's Compensation Injury | CHIEF COMPLAINT:, Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:, The patient is a 21-year-old Hispanic female. She comes in today with her boyfriend. The patient speaks English fairly well, but her primary language is Spanish. Her boyfriend does help to make sure that she understands what we are talkin... | null |
4,083 | A 3-month well-child check. | Consult - History and Phy. | Well-Child Check - 6 | SUBJECTIVE:, Patient presents with Mom and Dad for her 5-year 3-month well-child check. Family has not concerns stating patient has been doing well overall since last visit. Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack ... | consult - history and phy., denver ii, child check, mom, diet, growth, denver, family, development, child, check, |
4,084 | Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection. | Consult - History and Phy. | Well-woman checkup | CHIEF COMPLAINT:, The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:, She feels well. She has had no real problems. She has not had any vaginal bleeding. She had a hysterectomy. She has done fairly well from that time till now. She feels like she is doing pretty well. She remains sexually... | null |
4,085 | A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. | Consult - History and Phy. | Wound Care Consult | TYPE OF CONSULTATION:, Wound care consult.,HISTORY OF PRESENT ILLNESS:, The patient is a 62-year-old woman with a past medical history significant for prior ileojejunal bypass for weight loss (1980) and then subsequent gastric banding (2002 Dr. X) who was transferred to this facility following a complicated surgical ... | null |
4,086 | 1-year well child check. | Consult - History and Phy. | Well-Child Check - 4 | SUBJECTIVE:, The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. Normal voiding... | consult - history and phy., well child check, denver ii, child check, checkup, check, child, |
4,087 | 1-month-old for a healthy checkup - Well child check | Consult - History and Phy. | Well-Child Check - 7 | SUBJECTIVE:, This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.,PAST MEDI... | |
4,088 | A two week well-child check. | Consult - History and Phy. | Well-Child Check - 3 | SUBJECTIVE:, Patient presents with Mom for first visit to the office for two week well-child check. Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital. Nursing every two to three hours with normal voiding and stooling pattern. She does have a little bit of some ga... | null |
4,089 | Consultation for wrist pain. | Consult - History and Phy. | Wrist Pain | CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:, | consult - history and phy., wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar, |
4,090 | A 9-month well-child check. | Consult - History and Phy. | Well-Child Check - 2 | SUBJECTIVE:, This 9-month-old Hispanic male comes in today for a 9-month well-child check. They are visiting from Texas until the end of April 2004. Mom says he has been doing well since last seen. He is up-to-date on his immunizations per her report. She notes that he has developed some bumps on his chest that ha... | consult - history and phy., well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child, |
4,091 | Well child - Left lacrimal duct stenosis | Consult - History and Phy. | Well-Child Check - 1 | CHIEF COMPLAINT:, Well-child check.,HISTORY OF PRESENT ILLNESS:, This is a 12-month-old female here with her mother for a well-child check. Mother states she has been doing well. She is concerned about drainage from her left eye. Mother states she was diagnosed with a blocked tear duct on that side shortly after b... | consult - history and phy., well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child, |
4,092 | Patient with morbid obesity. | Consult - History and Phy. | Weight Loss Evaluation | REASON FOR VISIT:, Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:, | consult - history and phy., medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight |
4,093 | Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill. | Consult - History and Phy. | Viral Gastroenteritis | HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine." She states after vomiting, she felt "fine through the night," but woke with more nausea and v... | consult - history and phy., nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill, |
4,094 | This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder. | Consult - History and Phy. | Weight Gain and Edema | HISTORY OF PRESENT ILLNESS:, This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain. She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease... | null |
4,095 | Blood in urine - Transitional cell cancer of the bladder. | Consult - History and Phy. | Urology Consut - 1 | CHIEF COMPLAINT:, | null |
4,096 | Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty. | Consult - History and Phy. | Ventricular Ectopy - Consult | REASON FOR CONSULTATION:, Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS: ,I am seeing the patient upon the request of Dr. Y. The patient is a very well known to me. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior ... | null |
4,097 | The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia. | Consult - History and Phy. | Uveitis | PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:, Positive for only for left knee arthritis. She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers. She has no skin rashes. She has no connectiv... | consult - history and phy., iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation, |
4,098 | This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again. | Consult - History and Phy. | Urinary Retention | CHIEF COMPLAINT:, Urinary retention.,HISTORY OF PRESENT ILLNESS: , This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably sec... | null |
4,099 | The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment. | Consult - History and Phy. | Vertigo Consult | Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX... | consult - history and phy., electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo, |
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