Contusion of the orbital surface of the frontal lobes bilaterally

Closed head injury and history of fall

Headache, probably secondary to contusion

Neurology - Discharge Summary


Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.

Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.

Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.

Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.

Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.

Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.

Excision - Keratotic Neoplasm


No known drug allergies; no laboratory results extracted; no procedures extracted.

Accidental Celesta Ingestion - ER Visit


Schizoaffective disorder, bipolar type

Hepatitis C

Psychiatric Discharge Summary


No known allergies; no known medications; no known procedures; no known diagnoses; no vitals; no labs; no extraction_notes.

Sling (SPARC Suburethral)


Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.

No known allergies; no discharge summary extracted.

BMT & T&A


No known allergies; no known adverse reactions; no positive vitamin levels; no negative vitamin levels; no known drug interactions.

Down's syndrome


Buttock abscess

No known drug allergies; no positive blood cultures (no negative blood culture).

Buttock Abscess


, Kawasaki disease.

No known allergies; no positive drug allergies extracted.

Kawasaki Disease - Discharge Summary


Carious teeth #2, #5, #12, #15, #18, #19, and #31.

Left mandibular vestibular abscess

Extraction of teeth #2, #5, #12, #15, #18, #19, and #31.

Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.

Teeth Extraction & I&D


Diabetes type II uncontrolled

Acute cystitis

No known drug or alcohol abuse; no hernias noted.

Acute Cystitis & Diabetes Type II


No known allergies; no positive tuberculin or syphilis exposure; no other known significant allergies; no other known significant medical history (no hypertension, diabetes, cancer); no other known dental conditions (no previous tooth extraction, no other known dental work).

Uveitis


Bilateral C8 radiculopathies

No known allergies; no significant past medical history; no other laboratory results extracted.

EMG/Nerve Conduction Study - 1


Wasp sting to the right wrist area

Wasp Sting - SOAP


{"document_type": "lab_report", "patient": {"age": 50, "sex": "male"}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [], "procedures": [{"description": "Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy", "date": null, "department": null}], "discharge_summary": null, "medication_list": [], "allergies": [], "extraction_notes": "No known allergies; no known adverse reactions."""}

Laparoscopic Gastric Bypass - 1


, Recurrent dysplasia of vulva.

Carbon dioxide laser photo-ablation

Laser of Vulva


MRI Cervical Spine - 2


Progressive loss of color vision OD

Meningioma


No known allergies; no positive drug reactions; no other laboratory results extracted.

Ortho Office Visit


{"document_type": "lab_report", "patient": {"age": null, "sex": null}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [], "procedures": [{"description": "Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation", "date": null, "department": null}], "allergies": [], "extraction_notes": "No known allergies; no known medications."""}

Phacoemulsification & Cataract Extraction - 5


{"document_type": "lab_report", "patient": {"age": null, "sex": null}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [], "procedures": [], "allergies": [], "extraction_notes": "No known allergies, no positive drug reactions. No laboratory results extracted. No procedures extracted. No known diagnoses. No information on medications.")

Normal Physical Exam Template - 1


The patient was taken to the block room

He was placed prone on the fluoroscopy table

He was monitored appropriately

He was administered Versed 2 mg IV

His O2 saturation remained greater than 90%

His back was prepped and draped

The C-arm was brought in

The endplates at L5-S1 were squared off

The C-arm was rotated to the left

The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized

A 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique

The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle

No paresthesias were noted

One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized

The needle was flushed and removed

I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level

Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level

The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences

He was awake and alert, and taken to the recovery room in good condition

His left leg pain was relieved

Epidural Steroid Block