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4,600 | Consultation for left foot pain. | Chiropractic | Foot pain Consultation | CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to contin... | chiropractic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness |
4,601 | Evaluation for chronic pain program | Chiropractic | Knee & Back Pain | REASON FOR EVALUATION:, | null |
4,602 | The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. | Consult - History and Phy. | Abdominal Pain - Consult | CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evalua... | null |
4,603 | Consultation for wrist pain. | Chiropractic | Wrist Pain | CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:, | chiropractic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar, |
4,604 | MRI report Cervical Spine (Chiropractic Specific) | Chiropractic | MRI Cervical Spine - Chiropractic Specific | FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint... | chiropractic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint a... |
4,605 | Pain management for post-laminectomy low back syndrome and radiculopathy. | Chiropractic | Pain Management Consult - 1 | Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history bec... | chiropractic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome, |
4,606 | Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain. | Chiropractic | Chiropractic Initial Evaluation - 1 | HISTORY OF PRESENT COMPLAINT: ,Ms. Abc initially visited our office for the purpose of consultation and examination on December 1, 2004. Ms. Abc states that on November 16, 2004, she was in a parking lot, she was walking to her car, and stepped into a pothole. The patient reports that she fell backwards. The patient la... | null |
4,607 | Chiropractic IME with answers to questions from Insurance Company. | Chiropractic | Chiropractic IME - 1 | P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and th... | null |
4,608 | Chiropractic Evaluation for neck and low back pain following a car accident. | Chiropractic | Chiropractic Initial Evaluation - 2 | SUBJECTIVE COMPLAINTS: ,Constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. He also has pain and tightness in his low back increased on the left. His pain level is 7/10. He also states that since the accident, he has experienced tension headaches that b... | null |
4,609 | 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. | Cardiovascular / Pulmonary | 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 |
4,610 | Chiropractic IME with old files review. Detailed Thoracic Spine Examination. | Chiropractic | Chiropractic IME - 2 | DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is... | null |
4,611 | Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias | Cardiovascular / Pulmonary | VVIR Permanent Pacemaker Insertion | PROCEDURE PERFORMED:, Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:, Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failu... | cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads, |
4,612 | Patient with worsening shortness of breath and cough. | Cardiovascular / Pulmonary | Trouble breathing | CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smok... | null |
4,613 | Right and Left carotid ultrasound | Cardiovascular / Pulmonary | Ultrasound - Carotid - 1 | RIGHT:,1. Mild heterogeneous plaque seen in common carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3. Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%. ,4. Peak systolic velocity is normal in common carotid, bulb, and inte... | cardiovascular / pulmonary, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak ... |
4,614 | Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive t... | Cardiovascular / Pulmonary | Triple Lumen Catheter Insertion - 1 | PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED: ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:, The patient is an 86-year-old Cau... | cardiovascular / pulmonary, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire |
4,615 | Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc. | Chiropractic | Chiropractic Progress Note | CHIEF COMPLAINT: ,Hip pain.,HISTORY OF PRESENTING ILLNESS: ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Manage... | null |
4,616 | The patient was exercised according to standard Bruce protocol for 9 minutes. | Cardiovascular / Pulmonary | Treadmill Test | REASON FOR EXAMINATION:, Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress o... | cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram, |
4,617 | Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe. | Cardiovascular / Pulmonary | Transthoracic Echocardiography | REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricu... | cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic |
4,618 | Bilateral carotid ultrasound to evaluate pain. | Cardiovascular / Pulmonary | Ultrasound - Carotid - 2 | EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:, None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery. There are no different colors or spectral Doppler w... | cardiovascular / pulmonary, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing, |
4,619 | Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis. | Cardiovascular / Pulmonary | Triple Lumen Catheter Insertion | PREOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,PROCEDURE PERFORMED:,1. Insertion of a right brachial artery arteria... | cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle, |
4,620 | Urgent cardiac catheterization with coronary angiogram. | Cardiovascular / Pulmonary | Urgent Cardiac Cath | PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lido... | cardiovascular / pulmonary, cardiac catheterization, coronary angiogram, angiogram |
4,621 | Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram - 3 | REASON FOR EXAM: , Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS: ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:, Moderate stenosis of aortic valve replacement. Mild mitral regurgitation. Normal left ventricular function.,PROCEDURES IN DE... | cardiovascular / pulmonary, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate, |
4,622 | Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram - 6 | HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA caus... | cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic |
4,623 | Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram - 4 | PROCEDURE NOTE:, The patient was brought to the transesophageal echo laboratory after informed consent was obtained. The patient was seen by Anesthesia for MAC anesthesia. The patient's posterior pharynx was anesthetized with local Cetacaine spray. The transesophageal probe was introduced into the posterior pharynx... | cardiovascular / pulmonary, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve |
4,624 | Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram - 5 | CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower eso... | cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal |
4,625 | Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram - 2 | REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained. The patient was brought to special procedure unit. His throat was anesthetized with lidocaine spray.... | cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic, |
4,626 | Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines. | Cardiovascular / Pulmonary | Transesophageal Echocardiography Probe | INDICATIONS FOR PROCEDURE:, Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior ... | cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, ... |
4,627 | Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema. | Cardiovascular / Pulmonary | Tracheostomy Change | PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDI... | cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator |
4,628 | Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. | Cardiovascular / Pulmonary | Tracheostomy & SCOOP Procedure | PREOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1. Tracheostomy with skin flaps.,2. SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD L... | cardiovascular / pulmonary, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages |
4,629 | Transesophageal echocardiogram and direct current cardioversion. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram | EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM: ,1. Atrial fibrillation with rapid ventricular rate.,2. Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl. Following this... | null |
4,630 | Tilt table test. A patient with past medical history of syncope. The patient is also complaining of dizziness. | Cardiovascular / Pulmonary | Tilt Table Test - 1 | INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope. The patient is also complaining of dizziness. She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her bloo... | cardiovascular / pulmonary, vasovagal syncope, tilt table test, blood pressure, heart rate, dizziness, |
4,631 | Patient referred for evaluation of tracheostomy tube placement and treatment recommendations. | Cardiovascular / Pulmonary | Tracheostomy Tube Consult | HISTORY: ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement abo... | null |
4,632 | Tracheotomy for patient with respiratory failure. | Cardiovascular / Pulmonary | Tracheotomy - 1 | PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS: ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA: ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. General inhalational anesthesia was admin... | cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal, |
4,633 | Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative. | Cardiovascular / Pulmonary | Transesophageal Echocardiogram - 1 | INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: ,Procedure and complications explained to the patient in detail. Informed consent was obtained. The patient was anesthetized in the throat with lidocaine spray. Subsequently, 3 mg of IV Versed was given for sedation. The pa... | cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves |
4,634 | Aortic stenosis. Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart. | Cardiovascular / Pulmonary | Toronto Porcine Valve Insertion | PREOPERATIVE DIAGNOSIS:, Aortic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Aortic stenosis.,PROCEDURES PERFORMED,1. Insertion of a **-mm Toronto stentless porcine valve.,2. Cardiopulmonary bypass.,3. Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 300 cc.,INT... | cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta, |
4,635 | Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft. | Cardiovascular / Pulmonary | Thrombectomy | PREOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Loc... | cardiovascular / pulmonary, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis, |
4,636 | Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posteri... | Cardiovascular / Pulmonary | Thromboendarterectomy | OPERATIVE PROCEDURE,1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to th... | cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE |
4,637 | Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis. | Cardiovascular / Pulmonary | Thrombectomy AV Shunt | PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS: ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE: ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,D... | cardiovascular / pulmonary, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt, |
4,638 | Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels. | Cardiovascular / Pulmonary | Thoracotomy & Lobectomy | PREOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastin... | cardiovascular / pulmonary, upper lobe, intercostal nerve block, non-small-cell carcinoma, axillary lymph node, endo-gia, latissimus, lobectomy, lymph node dissection, lymphoma, pulmonary vein, serratus, thoracotomy, muscle sparing mini thoracotomy, upper lobectomy, staple gun, intercostal, |
4,639 | Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left. | Cardiovascular / Pulmonary | Thoracotomy & Pleurectomy | PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underw... | cardiovascular / pulmonary, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest |
4,640 | Tilt table test. Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome. | Cardiovascular / Pulmonary | Tilt Table Test | FINDINGS:,1. The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2. There was no significant change in heart rate or blood pressure on 80-degree tilt.,3. No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis... | cardiovascular / pulmonary, blood pressure, tilt table test, vasovagal, vasodepressor, orthostasisNOTE |
4,641 | Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. | Cardiovascular / Pulmonary | Thoracotomy & Bronchoscopy | PREOPERATIVE DIAGNOSIS:, Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1. Right thoracotomy, total decortication.,2. Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDIC... | cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural, |
4,642 | Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation. | Cardiovascular / Pulmonary | Thoracotomy & Esophageal Exploration | PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube ... | cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleura... |
4,643 | Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung. | Cardiovascular / Pulmonary | Thoracoscopy/Thoracotomy | PREOPERATIVE DIAGNOSES:, Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:, Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and d... | cardiovascular / pulmonary, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pl... |
4,644 | A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage. | Cardiovascular / Pulmonary | Thoracoabdominal Aneurysm | POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition ... | cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE |
4,645 | Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall. | Cardiovascular / Pulmonary | Thoracoscopy & Thoracotomy - Mesothelioma | PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1. Left thoracoscopy.,2. Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:, Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion... | cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy, |
4,646 | The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. | Cardiovascular / Pulmonary | Telemetry Monitoring | DIAGNOSES PROBLEMS:,1. Orthostatic hypotension.,2. Bradycardia.,3. Diabetes.,4. Status post renal transplant secondary polycystic kidney disease in 1995.,5. Hypertension.,6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. History of renal osteodystrophy.,8. Iron deficiency ane... | cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring, |
4,647 | Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula. | Cardiovascular / Pulmonary | Tessio Catheter Insertion | OPERATIONS/PROCEDURES,1. Insertion of right internal jugular Tessio catheter.,2. Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate ... | cardiovascular / pulmonary, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpo... |
4,648 | Thoracentesis. Left pleural effusion. Left hemothorax. | Cardiovascular / Pulmonary | Thoracentesis | PREOPERATIVE DIAGNOSIS:, Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:, After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was preppe... | cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest, |
4,649 | Quick note on tachypnea. | Cardiovascular / Pulmonary | Tachypnea | null | cardiovascular / pulmonary, chest, cpr, breath sounds, tachypnea, epinephrine, rhythmNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical tra... |
4,650 | Thoracentesis, left. Malignant pleural effusion, left, with dyspnea. | Cardiovascular / Pulmonary | Thoracentesis - 1 | PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE: ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room. After obtaining the informed consent, th... | cardiovascular / pulmonary, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural, |
4,651 | Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy. | Cardiovascular / Pulmonary | Tesio Hemodialysis Catheter Insertion | OPERATION,1. Insertion of a left subclavian Tesio hemodialysis catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operatin... | cardiovascular / pulmonary, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and... |
4,652 | The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation. | Cardiovascular / Pulmonary | Supraclavicular Lymphadenopathy | On review of systems, the patient admits to hypertension and occasional heartburn. She undergoes mammograms every six months, which have been negative for malignancy. She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, ano... | null |
4,653 | The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis. | Cardiovascular / Pulmonary | Supraventricular Tachycardia - Consult | HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents; however, did note the patient to be quite dusky since the time of her birth; however, ... | cardiovascular / pulmonary, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary, |
4,654 | Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. | Cardiovascular / Pulmonary | Subxiphoid Pericardiotomy | PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:, Subxiphoid pericardiotomy.,ANESTHESIA:, General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:, This is a 70-year-old black female who underwent a transhiatal esophage... | cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial |
4,655 | Emergent subxiphoid pericardial window, transesophageal echocardiogram. | Cardiovascular / Pulmonary | Subxiphoid Pericardial Window | PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxipho... | cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic |
4,656 | Chest pain, Chest wall tenderness occurred with exercise. | Cardiovascular / Pulmonary | Stress Test Graded Exercise Treadmill | INDICATIONS:, Chest pain.,PROCEDURE DONE:, Graded exercise treadmill stress test.,STRESS ECG RESULTS:, The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maxi... | cardiovascular / pulmonary, stress test, blood pressure, bruce protocol, chest pain, graded exercise, graded exercise treadmill, electrocardiogram, ischemia, sinus rhythm, treadmill, chest wall tenderness, chest wall, stress, chest, |
4,657 | Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity. | Cardiovascular / Pulmonary | Subclavian Central Venous Catheter Insertion | PREOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of... | cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion |
4,658 | Dobutrex stress test for abnormal EKG | Cardiovascular / Pulmonary | Stress Test Dobutrex | INDICATIONS:, | cardiovascular / pulmonary, dobutrex stress test, abnormal ekg, dobutrex, inferior abnormality, ischemic heart disease, ventricle, µg/kg/minute, stress test, stress, |
4,659 | Thallium stress test for chest pain. | Cardiovascular / Pulmonary | Stress Test Thallium | INDICATIONS: ,Chest pain.,STRESS TECHNIQUE:, | cardiovascular / pulmonary, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress |
4,660 | Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction. | Cardiovascular / Pulmonary | Stress Test Dobutamine Myoview | INDICATIONS: ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:, Dobutamine Myoview stress test.,STRESS ECG RESULTS:, The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minut... | cardiovascular / pulmonary, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusio... |
4,661 | Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. | Cardiovascular / Pulmonary | Subxiphoid Pericardial Window - 1 | OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and ... | cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial, |
4,662 | Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar. | Cardiovascular / Pulmonary | Stress Test Adenosine Myoview | INDICATIONS:, Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:, Adenosine Myoview stress test.,STRESS ECG RESULTS:, The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes. The bas... | cardiovascular / pulmonary, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusio... |
4,663 | Dobutamine stress test for atrial fibrillation. | Cardiovascular / Pulmonary | Stress Test Dobutamine | INDICATIONS:, Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:, The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT... | cardiovascular / pulmonary, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial |
4,664 | Stress test with Bruce protocol due to chest pain. | Cardiovascular / Pulmonary | Stress Test Bruce Protocol | PROTOCOL:, Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:, Chest pain.,PROCEDURE AND INTERPRETATION: ,1. Baseline heart rate: 67.,2. Baseline blood pressure: 150/86.,3. Total time: 6 minute 51 seconds.,4. METs: 10.1.,5. Peak heart rate: 140.,6. Percent of maximum-predicted heart rate: 90.,7. Peak ... | null |
4,665 | Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction | Cardiovascular / Pulmonary | Sick Sinus Syndrome | HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced d... | null |
4,666 | Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending. | Cardiovascular / Pulmonary | Stenting | NAME OF PROCEDURE:, Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:, Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:, Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail;... | null |
4,667 | The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. | Cardiovascular / Pulmonary | SOAP - Shortness of Breath | SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was s... | cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr, |
4,668 | Chest, Single view post OP for ASD (Atrial Septal Defect). | Cardiovascular / Pulmonary | Single Frontal View of Chest | EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis. Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:, Current film reveals there is a right-sided central venous catheter, the dis... | cardiovascular / pulmonary, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd |
4,669 | Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoa... | Cardiovascular / Pulmonary | SOAP - Lung Mass | SUBJECTIVE:, The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120... | cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation, |
4,670 | Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. | Cardiovascular / Pulmonary | Shiley Tracheostomy Tube Insertion | OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the op... | cardiovascular / pulmonary, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube, |
4,671 | Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter. | Cardiovascular / Pulmonary | Septal Defect Repair | TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagn... | cardiovascular / pulmonary, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous... |
4,672 | The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. | Cardiovascular / Pulmonary | Shortness Of Breath - Progress Note | She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has b... | cardiovascular / pulmonary, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE |
4,673 | Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins. | Cardiovascular / Pulmonary | Saphenous Vein - Ligation & Stripping | PREOPERATIVE DIAGNOSIS:, Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1. Ligation and stripping of left greater saphenous vein to the level of the knee.,2. Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approxi... | cardiovascular / pulmonary, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated, |
4,674 | Complete heart block with pacemaker malfunction and a history of Shone complex. | Cardiovascular / Pulmonary | Shone complex | HISTORY AND PHYSICAL: ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block. He is on the pacemaker. He had a coarctation of the aorta and that was repaired when he was an infant. He was followed in our Cardiology Clinic here and has been doing well. However last night, h... | null |
4,675 | Selective coronary angiography, coronary angioplasty. Acute non-ST-elevation MI. | Cardiovascular / Pulmonary | Selective Coronary Angiography & Angioplasty | PREOPERATIVE DIAGNOSIS AND INDICATIONS:, Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:, The patient presented with an acute non-ST-elevation MI. Despite medical therapy, she continued to have intermittent angina. Angiography demonstrated the severe LAD as the culprit lesion. This was treated as n... | cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent, |
4,676 | Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin. | Cardiovascular / Pulmonary | Radionuclide Stress Test | INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:, Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.... | cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia |
4,677 | A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever. | Cardiovascular / Pulmonary | Reactive Airway Disease | CHIEF COMPLAINT AND IDENTIFICATION:, A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and alb... | null |
4,678 | Pulmonary function test. Mild restrictive airflow limitation. Clinical correlation is recommended. | Cardiovascular / Pulmonary | Pulmonary Function Test - 5 | OBSERVATIONS: , FEV1 is 3.76, 103% predicted. FVC is 4.98, 110% predicted. Ratio is 75. FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%. DLCO is 35, 121% predicted. Residual volume is 3.04, 139% predicted. Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION... | cardiovascular / pulmonary, fev1, fvc, fef, dlco, lung capacity, postbronchodilator, pulmonary function test, restrictive airflowNOTE,: 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 ... |
4,679 | A 16-year-old male with Q-fever endocarditis. | Cardiovascular / Pulmonary | Q-Fever Endocarditis | HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports tha... | cardiovascular / pulmonary, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever, |
4,680 | Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy | Cardiovascular / Pulmonary | Pulmonary Valve Stenosis | HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare. This was complicated by shunt thrombosis __________ utilizing a 10-m... | cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure,... |
4,681 | Increasing oxygen requirement. Baby boy has significant pulmonary hypertension. | Cardiovascular / Pulmonary | Pulmonary Hypertension - Pediatric Consult | INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history o... | cardiovascular / pulmonary, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary |
4,682 | Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. | Cardiovascular / Pulmonary | Pulmonary Medicine Clinic Followup | SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and w... | cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, |
4,683 | Sample of Pulmonary Function Test | Cardiovascular / Pulmonary | Pulmonary Function Test - 4 | SPIROMETRY:, Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted. FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reve... | cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary, |
4,684 | This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. | Cardiovascular / Pulmonary | Pulmonary Edema - Consult | HISTORY: ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. History dates back to about six months of intermittent shortness of breath, intermittent very slight e... | null |
4,685 | Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. | Cardiovascular / Pulmonary | Pulmonary Embolism | REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:, The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest p... | null |
4,686 | Pulmonary Function Test in a patient with smoking history. | Cardiovascular / Pulmonary | Pulmonary Function Test - 1 | HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%. FEV1 was 45%. FEV1/FVC ratio was 52%. The predicted was 67%. FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator. SVC was 91%. Inspiratory capacity was 70%. Residual vol... | cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function, |
4,687 | Sample of Pulmonary Function Test | Cardiovascular / Pulmonary | Pulmonary Function Test - 3 | SPIROMETRY: , Spirometry reveals the FVC to be adequate.,FEV1 is also normal at 98% predicted and FVC is 90.5% predicted. FEF25-75% is also within normal limits at 110% predicted. FEV1/FVC ratio is within normal limits at 108% predicted.,After the use of bronchodilator, there is some improvement with 10%. MVV is wit... | cardiovascular / pulmonary, fvc, fev1, fev1/fvc ratio, fef, lung volumes, saturation on room air, pulmonary function test, pulmonary function, oxygen saturation, spirometry, bronchodilator, lung, diffusion, oxygen, saturation, pulmonary, capacity, |
4,688 | Pulmonary function test. Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy. | Cardiovascular / Pulmonary | Pulmonary Function Test | OBSERVATIONS: , The forced vital capacity is 2.84 L and forced expiratory volume in 1 second is 1.93 L. The ratio between the two is 68%. Small improvement is noted in the airflows after bronchodilator therapy. Lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of p... | cardiovascular / pulmonary, lung volume, forced expiratory volume, forced vital capacity, airflows, total lung capacity, bronchodilator therapy, bronchodilatorNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not ce... |
4,689 | Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study. | Cardiovascular / Pulmonary | Pulmonary Consultation - 1 | CHIEF COMPLAINT:, Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the ... | null |
4,690 | Patient with complaints of significant coughing and wheezing. | Cardiovascular / Pulmonary | Pulmonary Consultation - 2 | PAST MEDICAL HISTORY:, Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:, PENICILLIN.,CURRENT MEDICATIONS:, Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,The pat... | cardiovascular / pulmonary, pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing, |
4,691 | Pulmonary Function Test to evaluate dyspnea. | Cardiovascular / Pulmonary | Pulmonary Function Test - 2 | HISTORY:, Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:, FVC was 59%. FEV1 was 61%. FEV1/FVC ratio was 72%. The predicted was 70%. The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement. SVC was 69%. Inspiratory capacit... | cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, flow volume loop, pft, svc, smoking history, airway obstruction, bronchodilator, extrapulmonary, residual volume, restrictive lung disease, walking, pulmonary function, lung disease, pulmonary, function, lu... |
4,692 | The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. | Cardiovascular / Pulmonary | Pulmonary Atresia | HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. He also has VACTERL association with hydrocephalus. As an infant, he underwent placement of a right modified central shunt. On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulm... | null |
4,693 | Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. | Cardiovascular / Pulmonary | Port-A-Cath Insertion | PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Minimal.,PROCEDURE IN DETAIL: ,Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was perf... | cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire, |
4,694 | Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. | Cardiovascular / Pulmonary | Pulmonary - Followup Note | SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficul... | cardiovascular / pulmonary, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary, |
4,695 | Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures ... | Cardiovascular / Pulmonary | Pneumonia & COPD - Discharge Summary | ADMISSION DIAGNOSES:,1. Pneumonia, likely secondary to aspiration.,2. Chronic obstructive pulmonary disease (COPD) exacerbation.,3. Systemic inflammatory response syndrome.,4. Hyperglycemia.,DISCHARGE DIAGNOSES:,1. Aspiration pneumonia.,2. Aspiration disorder in setting of severe chronic obstructive pulmonary dis... | null |
4,696 | Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy. | Cardiovascular / Pulmonary | Port-A-Cath Insertion - 5 | PROCEDURES PERFORMED,1. Insertion of subclavian dual-port Port-A-Cath.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating ... | cardiovascular / pulmonary, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and qualit... |
4,697 | Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. | Cardiovascular / Pulmonary | Pneumoconiosis | HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time, he is admitted for continued,manag... | null |
4,698 | Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with... | Cardiovascular / Pulmonary | Preeclampsia | REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncon... | null |
4,699 | Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. | Cardiovascular / Pulmonary | Pneumonia - Discharge Summary | ADMISSION DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had s... | cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, |
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