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{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1300 }
HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She states that she continues with some joint pain and feeling tired all the time. Mother states that also her seizure has continued without any control so far. She is having some studies in the next few days. She is mostly stiff on her legs, neck, and also on her hands. The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT: She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations. Pupils are reactive to accommodation. Funduscopic examination is within normal limits.,NECK: No neck masses.,CHEST: Clear to auscultation.,HEART: Regular rhythm with no murmur.,ABDOMEN: Soft, nontender with no visceromegaly.,SKIN: No rashes today.,MUSCULOSKELETAL: Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D. She also has chronic proteinuria and seizure disorder. My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking. We are going to refer her to physical therapy and see her back in 2 months for followup. The plan was discussed with A and her parents and they have no further questions.consult - history and phy., arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1301 }
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 general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. 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. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1302 }
PREOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,4. Changes consistent with acute and chronic bronchitis.,5. Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6. Left vocal cord irregularity.,PROCEDURE PERFORMED: ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring. Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air. Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication. As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx. The cords were noted to oppose bilaterally on phonation. There was some slight mucosal irregularity noted on the vocal cord on the left side. Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature. The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled. At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled. Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion. The mucosa was diffusely friable throughout. Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled. At this point, the bronchoscope was then advanced to the right bronchus intermedius. At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening. The mucosal area throughout this region was severely friable. Additional lidocaine was instilled as well as topical epinephrine. At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed. At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible. So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized. At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty. At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius. At this time, multiple mucosal biopsies were performed with some mild oozing noted. Several aliquots of normal saline lavage followed. After completion of multiple biopsies there was good hemostasis. Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed. Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments. The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem. Additional lidocaine was instilled. The bronchoscope was advanced to the left upper and lower lobe subsegments. There was no endobronchial lesion visualized. There is mild diffuse erythema and fibromucosa was noted throughout. No endobronchial lesion was visualized in the left bronchial system. The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system. At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared. There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout. The bronchoscope was subsequently withdrawn and the patient was sent to recovery room. During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%. The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea. This was confirmed by her daughter and mother who were also present at the bedside postprocedure. The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well. The patient also admitted to continued smoking in spite of all of the above. The patient was extensively counseled regarding the continued smoking especially with her present symptoms. She was advised regarding smoking cessation. The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off. The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room. There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted. The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis. At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.surgery, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1303 }
CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play "Murder She Wrote" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the "assassin." Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a "chuckle.",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing "Murder She Wrote." She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was "Dementia of the Alzheimer's Type.",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of "old age." There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared "child-like" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:, CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1304 }
ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:, This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs. She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted. Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. She was interested in participating in the artificial disk replacement study and was entered into that study. She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. She has done well postoperatively with a sensation of right arm pain and numbness in her fingers. She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment. She will contact our office prior to her appointment if she has problems. Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill.surgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1305 }
PREOPERATIVE DIAGNOSES,1. A 40 weeks 6 days intrauterine pregnancy.,2. History of positive serology for HSV with no evidence of active lesions.,3. Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1. A 40 weeks 6 days intrauterine pregnancy.,2. History of positive serology for HSV with no evidence of active lesions.,3. Non-reassuring fetal heart tones.,PROCEDURES,1. Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2. Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS: ,None.,FINDINGS,1. Live male infant with Apgars of 9 and 9.,2. Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION: ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix. When she was admitted, her cervix was 2.5 cm dilated with 80% effacement. The baby had a -2 station. She had no regular contractions. Fetal heart tones were 120s and reactive. She was started on Pitocin for labor induction and labored quite rapidly. She had spontaneous rupture of membranes with a clear fluid. She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural. With the rapid cervical change and descent of fetal head, there were some variable decelerations. The baby was at a +1 station when the patient began pushing. I had her push to get the baby to a +2 station. During pushing, the fetal heart tones were in the 80s and did not recover in between contractions. Because of this, I recommended a vacuum delivery for the baby. The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation. The perineum was injected with 1% lidocaine. The bladder was drained. The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally. With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station. The contraction ended. The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s. With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station. A modified Ritgen maneuver was used to stabilize the fetal head. The vacuum was deflated and removed. The baby's head then delivered atraumatically. There was no nuchal cord. The baby's anterior shoulder delivered after a less than 30 second delay. No additional maneuvers were required to deliver the anterior shoulder. The posterior shoulder and remainder of the body delivered easily. The baby's mouth and nose were bulb suctioned. The cord was clamped x2 and cut. The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids. The placenta delivered spontaneously, was intact and had a three-vessel cord. A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration. The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia. The third-degree laceration was also repaired with #3-0 Vicryl sutures. Local anesthesia was used. The capsule was visible, but did not appear to be injured at all. It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well. She remains in the LDR with the baby. The baby is vigorous, crying and moving all extremities. He will go to the new born nursery when ready. The total time for repair of the laceration was 25 minutes.surgery, intrauterine pregnancy, non-reassuring fetal heart tones, vacuum-assisted vaginal delivery, vaginal side wall laceration, fetal heart tones, vaginal delivery, vacuum assisted, laceration, intrauterine, tones, contractions,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1306 }
EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right. The right renal pelvis is not dilated. There is no stone along the course of the ureter. I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised. There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder. No pelvic free fluid or adenopathy.,There are few scattered diverticula. There is a moderate amount of stool throughout the colon. There are scattered diverticula, but no CT evidence of acute diverticulitis. The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding. There is no stone identified along the course of the left ureter or in the bladder. Could this patient be status post recent stone passage? Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.nephrology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1307 }
PROCEDURE: , Skin biopsy, scalp mole.,INDICATION: ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1. K-Y jelly.,2. Betadine prep locally.,3. A 1% lidocaine with epinephrine local instilled.,4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.,IMPRESSION:, Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1308 }
HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee. This has required large amounts of opioid analgesics to control. She has been basically bedridden because of this. She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement. Difficult to assess individual muscles, but strength is largely intact. Sensory examination is symmetric. Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression. She has slightly decreased right versus left ankle reflexes. The Babinski's are positive. On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle. It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles. There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. Inactive right S1 (L5) radiculopathy.,2. There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.physical medicine - rehab, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1309 }
PREOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,OPERATION:, Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,ANESTHESIA: ,General.,INDICATIONS:, This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate. He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA: ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria. He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1. Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia. Prepped and draped in the dorsal lithotomy position. A 27-French Olympus rectoscope was passed via the urethra into the bladder. The bladder, prostate, and urethra were inspected. He had an obstructing prostate. He had marked catheter reaction in his bladder. He had a lot of villous changes, impossible to tell from frank tumor. He had a huge bladder calculus. It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone. There was still stone left at the end of the procedure. Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB. We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP. We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.urology, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1310 }
CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets. She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. The patient states she had been thinking about suicide for a couple of weeks. Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble. Reports she has been not socializing with her family because of her worsening depression. Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. They did as they have instructed and husband feels this may have had some factor on her worsening depression. The patient decided to ingest the pills when her husband went to work on Friday. She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. Her husband left around 7 in the morning and returned around 11 and found her sleeping. About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene. She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient. About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall. She was taken to Southwest Memorial Hermann Hospital. A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. Husband locked the gun after that and she was taken to Bellaire Hospital. The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days. She sees Dr. X once or twice weekly. He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active. Since then she has had worsening of her Huntington symptoms including short-term memory loss. At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's. Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's. The patient has told her husband that she does not want to go that way. The patient denies auditory or visual hallucinations, denies paranoid ideation. The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. Husband has stated that the patient's chorea becomes better when she takes Haldol. Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension. She has an upcoming appointment with the Neurologist. Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY: ,Strong family history for Huntington disease as per the HPI. Mother and grandmother died of Huntington disease. Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY: ,The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM: ,This is an elderly woman appearing stated age. Alert and oriented x4 with poor eye contact. Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. She is cooperative. Her speech is of low volume and slow rate and rhythm. Her mood is sad. Her affect is constricted. Her thought process is logical and goal-directed. Her thought content is negative for current suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. No command auditory hallucinations. No paranoia. Insight and judgment are fair and intact.,LABORATORY DATA:, A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality. U-tox positive for amphetamines and tricyclic antidepressants. Acetaminophen level 206.7, alcohol level 0. The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. She took 30 tablets of Haldol and 40 tablets of Tylenol. At present, the patient is without suicidal ideation. She reports that her worsening depression has coincided with her worsening Huntington disease. She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized. Her liver function tests are within normal limits.,AXIS I: Major depressive disorder due to Huntington disease, severe. Cognitive disorder, NOS.,AXIS II: Deferred.,AXIS III: Hypertension, Huntington disease, status post overdose.,AXIS IV: Chronic medical illness.,AXIS V: 30.,PLAN,1. Safety. The patient would be admitted on a voluntary basis to Main-7 North. She will be placed on every 15-minute checks with suicidal precautions.,2. Primary psychiatric issues/medical issues. The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3. Substance abuse. No acute concern for alcohol or benzo withdrawal.,4. Psychosocial. Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment. She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. We will place occupational therapy consult and social work consults.nan
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PREOPERATIVE DIAGNOSIS: ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:, Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position. Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position. A preoperative x-ray was obtained to identify the operative level and neck position. An incision was marked at the C4-C5 level on the right side. The incision was opened with #10 blade knife. Dissection was carried down through subcutaneous tissues using Bovie electrocautery. The platysma muscle was divided with the cautery and mobilized rostrally and caudally. The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection. The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia. This was opened with scissors and dissected rostrally and caudally with the peanut dissectors. The operative level was confirmed with an intraoperative x-ray. The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator. The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5. Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted. We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes. Operating microscope was draped and brought into play. Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went. We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally. Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch. There was a transligamentous disc herniation, which was removed during this process. We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent. Cord was seen to be pulsating freely behind the dura. There appeared to be no complications and the decompression appeared adequate. We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body. An 8 mm lordotic trial was used and appeared perfect. We then used a corticocancellous 8 mm lordotic graft. This was tapped into position. Distraction was released, appeared to be in excellent position. We then positioned an 18 mm Vector plate over the inner space. Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position. We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion. All of the screws locked to the plate and this was confirmed on visual inspection. Intraoperative x-ray was again obtained. Construct appeared satisfactory. Attention was then directed to closure. The wound was copiously irrigated. All of the self-retaining retractors were removed. Bleeding points were controlled with bone wax and bipolar electrocautery. The platysma layer was now closed with interrupted 3-0 Vicryl sutures. The skin was closed with running 3-0 Vicryl subcuticular stitch. Steri-Strips were applied. A sterile bandage was applied. All sponge, needle, and cottonoid counts were reported as correct. The patient tolerated the procedure well. He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.neurosurgery, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,
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PREOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic rotator cuff debridement.,2. Anterior acromioplasty.,3. Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital. This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention. He was refractory to conservative outpatient therapy. He had injection of his AC joint, which removed symptoms but was not long lasting. After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side. All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum. The remainder of the rotator cuff observed was noted to be intact. Subacromially, the patient was noted to have increased synovitis. Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position. He was prepped and draped in the usual sterile manner. Portals were created posteriorly and anteriorly from outside to in. A full and complete diagnostic intraarticular arthroscopy was carried out. Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff. Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region. The scope was directed subacromially. A portal was created laterally. Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle. Gross bursectomy was carried out with a 4.2 meniscal shaver. #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200. Because of this and difficulties with his anesthetic, it was elected to change to an open procedure. Thus, the patient was anesthetized safely and secured. An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue. Hemostasis was controlled via electrocoagulation. Flaps were created. Anterior deltoid was reflected inferiorly. Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp. An excellent decompression was present. CA ligament had been previously resected. We then took the incision over the distal clavicle. The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw. The beaver-tail rasp was utilized to smooth off the edges. Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl. Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same. A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally. Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing. 0.25% Marcaine was flooded into the joint prior to the skin closure. Pain buster catheter was hooked up. The patient's arm was placed in arm sling. He was safely transferred to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair.surgery, slap lesion, acromioclavicular joint, impingement syndrome, mumford procedure, acromioplasty, arthroscopy, arthroscopic, arthroscopic rotator cuff debridement, anterior acromioplasty, rotator cuff tear, arthroscopic rotator, meniscal shaver, cuff tear, rotator cuff, debridement, osteoarthritis, acromioclavicular, clavicle, deltoid, rotator, cuff, shoulder, joint
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REVIEW OF SYSTEMS:,CONSTITUTIONAL: Patient denies fevers, chills, sweats and weight changes.,EYES: Patient denies any visual symptoms.,EARS, NOSE, AND THROAT: No difficulties with hearing. No symptoms of rhinitis or sore throat.,CARDIOVASCULAR: Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY: No dyspnea on exertion, no wheezing or cough.,GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU: No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge.,MUSCULOSKELETAL: No myalgias or arthralgias.,NEUROLOGIC: No chronic headaches, no seizures. Patient denies numbness, tingling or weakness.,PSYCHIATRIC: Patient denies problems with mood disturbance. No problems with anxiety.,ENDOCRINE: No excessive urination or excessive thirst.,DERMATOLOGIC: Patient denies any rashes or skin changes.general medicine, review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary
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PREOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room. The abdominal contents were within normal limits. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution. A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area. Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges. Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery. Mild adhesions were lysed. The omentum was freed. The small and large intestine were run with no evidence of abnormalities. The liver and gallbladder were within normal limits. No abnormalities were noted. At this point, the Bookwalter retractor was placed. NG tube was placed in the stomach and placed on suction. The intestines were gently packed intraabdominally and laterally. The rest of the peritoneum was then opened. The aorta was cleared, both proximally and distally. The left iliac was completely occluded. The right iliac was to be cleansed. At this point, 5000 units of aqueous heparin was administered to allow take effect. The aorta was then clamped below the renal arteries and opened in a longitudinal fashion. A single lumbar was ligated with #3-0 Prolene. The inferior mesenteric artery was occluded intraluminally and required no suture closure. Care was taken to preserve collaterals. The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion. Last stitch was tied. Hemostasis was excellent. The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis. At this point, strong pulses were present within the graft. The limbs were vented and irrigated. Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin. The grafts were then brought through these, care being taken to avoid twisting of the graft. At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed. Hemostasis was excellent. The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors. The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion. Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied. Flow was initially restored proximally then distally with good results. Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally. The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis. The last stitch was tied. Strong pulses were present within the artery and graft itself. At this point, 25 mg of protamine was administered. The wounds were irrigated with antibiotic solution. The groins were repacked. Attention was then returned to the abdomen. The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present. The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft. The intraabdominal contents were then allowed to resume their normal position. There was no evidence of ischemia to the large or small bowel. At this point, the omentum and stomach were repositioned. The abdominal wall was closed in a running single layer fashion using #1 PDS. The skin was closed with skin staples. The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips. The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well. Sponges and instrument counts were correct. Estimated blood loss 900 cc.cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,
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EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm. There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right. Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology. This could represent a large hemorrhagic cyst versus abscess. There is no evidence for left ovarian torsion. There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm. The endometrial echo is normal at 6 mm.,IMPRESSION:,1. No evidence for torsion.,2. Large, complex cystic left ovarian mass as described. This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded. Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.radiology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion,
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PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.,PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty. The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used. The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty. The guidewire was removed. Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty. The ports were flushed with injectable normal saline secondary to the patient going for dialysis today. Thus, he will not need heparinization of the lines. Again, he tolerated the procedure well. A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.surgery, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein
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PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.ent - otolaryngology, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,
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PREOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1. Austin/Youngswick bunionectomy with Biopro implant.,2. Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint. The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time. The patient desires surgical treatment.,PROCEDURE IN DETAIL: , An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint. Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon. The incision was then deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was undermined medially, off of the joint capsule. A dorsal linear capsular incision was then made. Care was taken to identify and preserve the extensor hallucis longus tendon. The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx. There was noted to be a significant degenerative joint disease. There was little to no remaining healthy articular cartilage left on the head of the first metatarsal. There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx. A sagittal saw was then used to resect the base of the proximal phalanx. Care was taken to ensure that the resection was parallel to the nail. After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact. The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal. The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp. The sizers were then inserted for the Biopro implant. A large was noted to be of the best size. There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx. Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base. A small bar drill was then used to pre-drill for the Biopro sizer. The bone was noted to be significantly hardened. The sizer was placed and a large Biopro was deemed to be the correct size implant. The sizer was removed and bar drill was then again used to ream the medullary canal. The hand reamer with a Biopro set was then used to complete the process. The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit. There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal. A long dorsal arm Austin osteotomy was then created. A second osteotomy was then created just plantar and parallel to the first osteotomy site. The wedge was then removed in toto. The area was feathered to ensure high compression of the osteotomy site. The head was noted to be in a more plantar flexed position. The capital fragment was then temporarily fixated with two 0.45 K-wires. A 2.7 x 16 mm screw was then inserted in the standard AO fashion. A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion. With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash. A screw driver was then used to check and ensure screw tightness. The area was then flushed with copious amounts of sterile saline. Subchondral drilling was performed with a 1.5 drill bit. The area was then flushed with copious amounts of sterile saline. Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl. Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban. A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well. The patient was transported to PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q. 4-6h. p.o. p.r.n. pain. The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema. The patient is to follow up with Dr. X in his office as directed.orthopedic, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1319 }
PREOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,PROCEDURE PERFORMED: ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened. A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid. This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE: ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution. Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The platysmal muscle was divided. The carotid sheath was identified and opened. The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided. The common internal and external carotids were then freed from the surrounding tissue. At this point, 10,000 units of aqueous heparin were administered and allowed to take effect. The external and common carotids were then clamped. The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure. The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid. The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external. The plaque tapered nicely on the internal and no tacking sutures were necessary. Heparinized saline was injected and no evidence of flapping or other debris was noted. The remaining carotid was examined under magnification, which showed no debris of flaps present. At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion. Prior to the time of last stitch, the internal carotid was back-bled through this. The last stitch was tied. Hemostasis was excellent. The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system. At this point, a total of 50 mg of Protamine was administered and allowed to take effect. Hemostasis was excellent. The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl. The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well. Sponge, needles, and instrument count were correct. Estimated blood loss was 250 cc.cardiovascular / pulmonary, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1320 }
PREOPERATIVE DIAGNOSES:,1. Depressed anterior table frontal sinus fracture on the right side.,2. Right nasoorbital ethmoid fracture.,3. Right orbital blowout fracture with entrapped periorbita.,4. Nasal septal and nasal pyramid fracture with nasal airway obstruction.,POSTOPERATIVE DIAGNOSES:,1. Depressed anterior table frontal sinus fracture on the right side.,2. Right nasoorbital ethmoid fracture.,3. Right orbital blowout fracture with entrapped periorbita.,4. Nasal septal and nasal pyramid fracture with nasal airway obstruction.,OPERATION:,1. Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus.,2. Transconjunctival exploration of right orbital floor with release of entrapped periorbita.,3. Open reduction of nasal septum and nasal pyramid fracture with osteotomy.,ANESTHESIA:, General endotracheal anesthesia.,PROCEDURE: , The patient was placed in the supine position. Under affects of general endotracheal anesthesia, head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion. A gull-wing incision was drawn over the forehead scalp. Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to, but not including the pericranium. An inferiorly based forehead flap was then elevated to the superior orbital rim. The depression of the anterior table of the frontal sinus was noted. An incision was made more posterior creating an inferiorly based pericranial flap. The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap. These allowed exposure of the medial orbital wall on the right side. The displaced fractures of the right medial orbital wall were repositioned through coronal approach. ,Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall. The anterior table fracture was satisfactorily reduced. Multiple 1.3-mm screws and plate fixation were utilized to recontour the anterior forehead. A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall. A sinus seeker was utilized and passed into the nasofrontal duct without difficulty. It was felt that the frontal sinus obliteration would not be necessary.,At this point, the pericranial flap was folded in a fan-folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead. At this point, the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies, which were made medially, laterally, and percutaneous transverse osteotomy of the nasal bone on the right side. There is significant depression of the nasal bone on the left side. A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily. There is a high septal deviation, which would not allow complete correction of the deviation. It was felt that this would best be left for a later date. Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally. Local infiltration anesthesia 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim. An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion. Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor. Hemostasis was achieved with electrocautery. There was entrapped periorbita, which was released to the fractures, which were repositioned, but not fixed in position. The forced ductions were performed, which demonstrated release of the periorbit satisfactorily. The conjunctival incision was closed with an interrupted simple 6-0 plain gut suture. The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum. The coronal incision was closed with interrupted 3-0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples. Nose was dressed with Steri-Strips. Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3-0 Prolene suture and the nose packed with two Kennedy Merocel sponges. A supportive mildly compressive dressing with fluffs, Kerlix, and 4-inch Ace were applied. The patient tolerated the procedure well and was returned to recovery room in satisfactory condition.ent - otolaryngology, frontal sinus, nasal septal, transconjunctival, anterior table, ethmoid, ethmoid fracture, gull-wing incision, nasal airway obstruction, nasal pyramid, nasoorbital, osteotomy, phisohex, periorbita, depressed anterior table, nasal pyramid fracture, sinus fractures, inferior orbital, pyramid fracture, entrapped periorbita, orbital, fractures, nasal, frontal, forehead, sinus,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1321 }
PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:, None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma. She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X. It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. Consent was obtained. The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted. A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. She tolerated this procedure very well.surgery, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage
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PREOPERATIVE DIAGNOSES:,1. Chronic nasal obstruction secondary to deviated nasal septum.,2. Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Chronic nasal obstruction secondary to deviated nasal septum.,2. Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1. Nasal septal reconstruction.,2. Bilateral submucous resection of the inferior turbinates.,3. Bilateral outfracture of the inferior turbinates.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction. On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE: ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained. The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away. Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities. These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution. The nasal pledgets were then reinserted as the patient was prepped in the usual fashion. The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution. The nasal vestibules were then cleansed with a pHisoHex solution. A #15 blade scalpel was then used to make an incision along the length of the caudal septum. The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor. Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle. At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity. Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur. At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur. Again, the mucosal flap was elevated in the right nasal septum. Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps. A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side. Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel. Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms. Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone. The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone. Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages. Inspection revealed very patent and nonobstructive nasal passages. Now the caudal incision was reapproximated with #4-0 chromic suture. Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion. Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.surgery, chronic nasal obstruction, nasal septum, inferior turbinate hypertrophy, nasal septal reconstruction, submucous resection, inferior turbinates, outfracture, nasal septal, nasal pledgets, nasal cavity, nasal obstruction, turbinate hypertrophy, mucosal flap, septal, septum, turbinates, nasal, cavity, chronic, hypertrophy, obstruction, mucosal,
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HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED: ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver. No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION: ,1. Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2. Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3. Hypercholesterolemia.,4. History of anxiety.,5. History of coronary artery disease.,6. Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X. Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation. I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis
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XYZ, D.C.,Re: ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side. The patient sustained impact injuries to his neck and lower back. There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures. He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg. He has had no difficulty with bowel or bladder function. He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:, He was injured in a prior motor vehicle accident on MM/DD/YYYY. At the time of his most recent injuries, he was completely symptom free and under no active therapy. There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS: ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:, Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level. MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function. Vital Signs: Blood pressure was 105/68 in the left arm sitting. Heart rate was 70 and regular. Height was 5 feet 8 inches. Weight was 182 pounds. Cranial nerve evaluation was unremarkable. Pupils were equal and reactive. Funduscopic evaluation was clear. There was no evidence for nystagmus. There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature. Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ symmetrical and active. No pathological responses were noted. Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity. Cerebellar function was normal. There was normal station and gait. Chest and cardiovascular evaluations were unremarkable. Heart sounds were normal. There were no extra sounds or murmurs. Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY. In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms. Palpable trigger points were noted on today's evaluation. He is suffering from ongoing myofascitis. His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time. I have encouraged him to continue with his ongoing treatment program under your care and supervision. I will be following him in two weeks' time. Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,letters, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho,
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EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.orthopedic, collateral ligament, mri, knee, collateral, sprain, medial, ligament,
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PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,6. Grade 1+ rectocele.,PROCEDURE PERFORMED: ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery. She has heavy periods lasting 7 to 14 days with spotting in between her periods. The patient's uterus is 12.2 x 6.2 x 5.3 cm. Her endometrial thickness is 2 cm. Her adnexa is within normal limits. The patient and I had a long discussion. Consent was reviewed in layman's terms. The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery. Questions were answered. The patient was taken back to the operative suite. The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position. The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities. The patient's history is that she is at risk for development of condyloma. The patient's husband was found to have a laryngeal papillomatosis. She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation. Her uterus appears to be mobile by 12-week size. There is a good descend. There appears to be no adnexal abnormalities. Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis. The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens. The patient underwent hysteroscopy. The outflow valve was opened at all times. The inflow valve was opened just to achieve appropriate distension. The patient did have no evidence of trauma of the cervix. No Trendelenburg as we were in room #9. The patient also had the bag held two fingerbreadths above the level of the heart. The patient was seen. There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature. The patient also has one in the fundal area. The thickened tissue was removed via sharp curettage. Therefore, we reinserted the hysteroscope. It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed. The patient's procedure was ended with specimen being obtained and sent to Department of Pathology. We will follow her up in the office.surgery, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus
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TITLE OF OPERATION: ,1. Arthrotomy, removal humeral head implant, right shoulder.,2. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3. Debridement glenohumeral joint.,4. Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X. However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis. Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,3. Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position. A Foley catheter was placed in his bladder. He was then placed in a beach chair position. He was brought to the side of the table and the torso secured with towels and tape. His head was then placed in the neutral position with no lateral bending or extension. It was secured with paper tape over his forehead. Care was taken to stay off his auricular cartilages and his orbits. Right upper extremity was then prepped and draped in the usual sterile fashion. The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection. Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep. This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case. Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally. The patient had significant amount of scar already in this interval. Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar. This created a significant amount of bleeding. As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus. Care was taken to stay above the pectoralis minor and the conjoint tendon. The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus. Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component. It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin. The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity. The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released. The brachial plexus was identified as was the axillary nerve. Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later. This revealed sanguineous fluid inside the joint. We did not feel it was infected based upon the fluid that came from the joint. The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures. The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously. Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring. This was done also very meticulously. The upper one half of the latissimus dorsi tendon was also released. Once this was completed, the humerus could be subluxed enough laterally that we could remove the head. This was done with no difficulty. Fortunately, the humeral component stayed intact. There were some exudates beneath the humeral head, which were somewhat mucinous. However, these do not really appear to be infected, however, we sent them to pathology for a frozen section. This frozen section later returned as possible purulent material. I discussed this personally with the pathologist at that point. We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect. As a result, all the mucinous exudates were carefully removed. We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation. At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain. This came back as no organisms seen. We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid. The patient had significant amount of scar already. The subscapularis itself was significantly scarred down to the anterior rim. As a result, the adhesions along the anterior edge were released using a knife. Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus. Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis. The subscapularis was then tagged with multiple number 2 Tycron sutures. Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension. As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus. These all had excellent security in bone. Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus. Care was taken to remove fluid off the Morse taper. The head was then impacted. It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient. Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus. As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component. The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion. Also, it should be noted that the rotator cuff interval had to be released as part of the exposure. We started the repair by closing the rotator cuff interval. Anterior and posterior translation was then performed and was found to be very stable. The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained. This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon. After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side. Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation. It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation. The rotator cuff interval was closed with multiple number 2 Tycron sutures. It was reinforced with 0 Vicryl sutures. Two Hemovac drains were then placed inferiorly at the deltoid. The deltopectoral interval was then closed with 0 Vicryl sutures. A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections. This was sewn into place with the drain pulled out superiorly. Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered. There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case. This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement. Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant. This was being dictated for insurance purposes only and reflects no inherent difficulties with this case. The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair. This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker. This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.surgery, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1328 }
INDICATIONS:, Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:, Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:, Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview. Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY. The lung heart ratio is 0.34. There appears to be a moderate size inferoapical perfusion defect of moderate degree. The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:, Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY. We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1329 }
ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS: ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell. She states that she woke yesterday morning and at approximately 10:30 had a bowel movement. She noticed it was very dark and smelly. She said she felt okay. She got up. She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out. She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools. She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued. She came to place her call, etc. She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday. She denies any nausea except for when she got weak. She denies any vomiting or any other symptoms.,ALLERGIES: ,She has no known drug allergies.,CURRENT MEDICATIONS:,1. Lipitor, dose unknown.,2. Paxil, dose unknown.,3. Lasix, dose unknown.,4. Toprol, dose unknown.,5. Diphenhydramine p.r.n.,6. Ibuprofen p.r.n.,7. Daypro p.r.n.,PAST MEDICAL HISTORY:,1. Non-insulin diabetes mellitus.,2. History of congestive heart failure.,3. History of hypertension.,4. Depression.,5. Arthritis. She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6. Hyperlipidemia.,7. Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:, She is a nonsmoker. She occasionally has a drink every few weeks. She is divorced. She has 2 sons. She is houseparent at Southern University.,REVIEW OF SYSTEMS: ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE: ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS: Currently was stable. She is afebrile.,GENERAL: She is alert, pleasant in no acute distress. She does complain of some dizziness when she stands up.,HEENT: Pupils equal, round and reactive to light. Extraocular muscles intact. Sclerae clear. Oropharynx is clear.,NECK: Supple. Full range of motion.,CARDIOVASCULAR: She is slightly tachycardic but otherwise normal.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended. She has no hepatomegaly.,EXTREMITIES: No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:, Her initial chem panel was within normal limits. Her PT and PTT were normal. Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6. She is currently administered transfusion. Platelet count was 125. Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7. PT and PTT were normal. Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1. Gastrointestinal bleed.nan
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1330 }
REASON FOR CONSULTATION:, New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease. We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain. Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened. Eventually this prompted him to present to the emergency room. A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease. At that point, he was transferred to XYZ Hospital for further evaluation. On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes. The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum. This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery. There was an abnormal lymph node noted in the AP window and left hilar region. There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm. There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease. There were areas of atelectasis particularly in the right base. There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing. There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax. In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor. All other structures appeared normal. On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed. Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma. At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite. He has not ever had a chronic smoker's cough and still does not have a cough. He has no sputum production or hemoptysis. He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain. He does take a multivitamin on occasion.,SOCIAL HISTORY: He has about a 30-pack-a-year history of smoking. He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked. Since that time he has worked with printing press. He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications. He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL: He has lost about 20 pounds of weight as described above. He also has a trouble with fatigue. No lightheadedness or dizziness. HEENT: He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year. He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain. RESPIRATORY: He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest. No cough, congestion, wheezing, hemoptysis, and sputum production. CVS: He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities. GI: He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools. He has been somewhat constipated recently. GU: He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems. MUSCULOSKELETAL: He denies any new bony aches or pains including back pain, hip pain, and rib pain. No muscle aches, no joint swelling, and no history of gout. SKIN: No rashes, no bruising, petechia, non-healing wounds, or ulcerations. He has had no nail or hair changes. HEM: He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps. ENDOCRINE: He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors. NEURO: He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS: His T-max is 98.8. His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL: No acute distress, pleasant gentleman who appears stated age.,HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without erythema, exudate, or discharge.,NECK: Supple. Nontender. No elevated JVP. No carotid bruits. No thyromegaly. No thyroid nodules. Carotids are 2+ and symmetric.,BACK: Spine is straight. No spinal tenderness. No CVA tenderness. No presacral edema.,CHEST: Clear to auscultation and percussion bilaterally. No wheezes, rales, or rhonchi. Normal symmetric chest wall expansion with inspiration.,CVS: Regular rate and rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly. No guarding or rebound. No masses. Normoactive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. No joint swelling. Full range of motion.,SKIN: No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC: Cranial nerves II through XII are intact. He has intact sensation to light touch throughout. He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes. He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000. The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils. Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7. His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:, MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter. There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable. His wife particularly had a very hard time with this prognosis. They preferred not to know the exact average as to how long someone lives with this disease. I did offer chemotherapy as a way to treat this disease. Chemotherapy has been associated both with palliation of symptoms as well as prolong survival. At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal. I would likely use carboplatin and gemcitabine. This would be both medications given on day 1 with a dose of gemcitabine on day 8. This cycle will be repeated after 1-week break so that the cycle lasts 21 days. The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging. A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain. He will be ready to be discharged from the hospital once his pain is under better control. As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday. At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.nan
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1331 }
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 0.5 cm right inferior breast lateral.,POSTOPERATIVE 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 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case.nan
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CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,
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HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have hemoglobin of 9 and MCV 65. The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off. Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago. At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature. The patient also was diagnosed with lymphocytic colitis. He was not treated for diarrhea for more than 3 years.,PAST MEDICAL HISTORY: , Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.,MEDICATIONS: , Iron supplement.,ALLERGIES: ,The patient has no known drug allergies.,FAMILY HISTORY:, Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.,SOCIAL HISTORY:, The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any drug use.,REVIEW OF SYSTEMS: , The patient has no night sweats. Good appetite. Stable weight. No chills, no fevers. No visual problems. No hearing problems. The patient denies any difficulty swallowing, any nausea or vomiting, any burning sensation in the esophagus. The patient has had chronic diarrhea for more than 3 years. His stool is daily, 1-2 times per day and very loose. He also admitted to have dark and bright blood in the stool on and off for more than 5 months. Respiratory review of systems was significant for COPD. The patient is not on oxygen and his COPD is mild. He denies any neurological problems, psychiatric problems, endocrine problems, hematological problems, lymphatic problems, immunological problems, allergy problems. The patient had recent episode of significant skin itching all over the body.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight 221 pounds. Height 6 feet 1 inch. Blood pressure 124/62, heart rate 87, temperature 98.4, saturation 98%. Pain is 0/10.,GENERAL: Well-developed, well-nourished, normal asthenic. Good attention to grooming.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions. Good dentition.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilaterally. No wheezing, no rhonchi, no crackles.,CARDIOVASCULAR: Regular rate and rhythm. The patient had 2/6 systolic ejection murmur on aortic valve projected to carotid artery. No rubs, no gallops. No JVD. Peripheral pulses 2+ in both radialis and both dorsalis pedis bilaterally.,ABDOMEN: No masses, no tenderness. No distention. No hepatosplenomegaly. Bowel sounds present.,RECTAL: Good sphincter tone. No palpable nodules. No masses. No blood. Dark stool, the patient is taking iron. Test was sent for occult blood test.,BACK: No costovertebral tenderness bilaterally.,LYMPHATICS: The patient had no neck, axial, groin or supraclavicular lymphadenopathy on exam.,MUSCULOSKELETAL: The patient had good, stable gait. No clubbing, no cyanosis, no pitting edema. Full range of motion. No joint deformities.,SKIN: Clear of rashes and lesions. No ulcers.,NEUROLOGICAL: Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both knees and both biceps. Babinski negative bilaterally. Good control of bowel and urinary bladder. No local weakness.,PSYCHIATRIC: The patient had good judgment and insight. Oriented x4. Good recent and remote memory. Appropriate mood and affect.,ASSESSMENT & PLAN: ,The patient is a 55-year-old gentleman with iron deficiency anemia, blood in the stool. The patient needs evaluation for source of bleeding with a colonoscopy. The patient was explained rationale, risks, benefits, and alternatives of the procedure. He accepted the recommendation. Colonoscopy scheduled. The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality. The patient had multiple tests from a previous examination. One of the pathology reports from Dr. X from 2003 showed lymphocytic microscopic colitis, hyperplastic polyps. Reviewed also multiple lab tests including CBC, CMP. The patient had Coombs' test negative. His reticulocyte count is 2.41. His iron TIBC 514, serum iron 29, ferritin 7. He had no liver function test abnormality. PSA was in the normal range. The patient had x-ray which showed pulmonary hyperinflation and emphysema. The patient will be followed up with result of colonoscopy.nan
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HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005. She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved. Since that time she has had right low neck pain and left low back pain. She has been extensively worked up and treated for this. MRI of the C & T spine and LS spine has been normal. She has improved significantly, but still complains of pain. In June of this year she had different symptoms, which she feels are unrelated. She had some chest pain and feeling of tightness in the left arm and leg and face. By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg. Symptoms lasted for about two days and then resolved. However, since that time she has had intermittent numbness in the left hand and leg. The face numbness has completely resolved. Symptoms are mild. She denies any previous similar episodes. She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function. There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination. Normal gait. Cranial nerves are intact. Sensory examination reveals normal facial sensation. She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities. In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot. In this area she has normal light touch and pinprick. She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle. It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal. There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy. EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident. This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year. Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms. Once she has the test done she will phone me and further management will be based on the results.physical medicine - rehab, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction,
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PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,PROCEDURES PERFORMED: ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:, Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:, A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw. A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position. At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis. Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site. The right foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg. Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made. The incision was carried deep utilizing both sharp and blunt dissections. All major neurovascular structures were avoided. At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified. This was then incised fully exposing the tendon and the abductor hallucis muscle. This was then resected from his osseous attachments and a small tenotomy was performed. At this time, a small lateral capsulotomy was also performed. Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision. The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field. A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye. The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position. The dorsal arm was made longer than the plantar arm to accommodate for fixation. At this time, the capital fragment was resected and shifted laterally into a more corrected position. At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation. Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site. Compression was noted to be excellent. All guide wires and 0.045-inch K-wires were then removed. Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field. The wound was then once again flushed with copious amounts of sterile normal saline. At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated. At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon. At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension. Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal. Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field. Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head. The head was then shifted medially into a more corrected position. A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site. This was noted to be in correct position and compression was noted to be excellent. Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field. The wound was once again flushed with copious amounts of sterile normal saline. The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon. At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site. The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion. The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot. The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot. After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A. The patient is to be nonweightbearing to the right foot. The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these. The patient tolerated the procedure and anesthesia well. Dr. A was present throughout the entire case.surgery, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis,
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EXAM:, CT head.,REASON FOR EXAM:, Seizure disorder.,TECHNIQUE:, Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction. There is no midline shift, intracranial mass, or mass effect. There is no extra-axial fluid collection or hydrocephalus. Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:, No acute process in the brain.radiology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast,
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REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY: ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:, Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY: ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT: Atraumatic.,NECK: Soft and supple.,LUNGS: Bilaterally diminished.,HEART: Regular.,ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:, Have her admitted to the medical service for treatment of her hyponatremia.nan
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PREOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:, Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:, Topical.,COMPLICATIONS:, None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision. They were found to have a visually significant cataract. The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the operating room. A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion. A paracentesis was created at ** o'clock. The anterior chamber was filled with Viscoat. A clear corneal incision was made at ** o'clock with the 3-mm diamond blade. A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps. The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag. The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion. The residual cortex was removed with the irrigation/aspiration handpiece. The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well. The residual Provisc was removed with the irrigation/aspiration handpiece. The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution. The wounds were found to be free from leak. Zymar and Pred Forte were instilled postoperatively. The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications. He will follow up with us in one day.surgery, nuclear sclerotic cataract, intraocular lens, cataract, kelman phacoemulsification, sclerotic cataract, posterior chamber, capsular bag, eye, anesthesia, phacoemulsification
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PROCEDURES:, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:, History and physical examination was performed. The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this. Opportunity for questions was provided and informed consent was obtained.,MEDICATION: ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:, None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx. The esophageal mucosa and vascular pattern appeared normal. The lower esophageal sphincter was located at 25 cm from the central incisors. It appeared normal. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which distended with excess air. Rugal folds flattened completely. Gastric mucosa appeared normal throughout. No hiatal hernia was noted. Pyloric valve appeared normal. The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional 2 biopsies were obtained for CLO testing in the antrum. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of procedure well. The patient was turned and the scope was advanced with some difficulty to the terminal ileum. The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted. Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum. Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3. The polyp was severed. There was no bleeding at the stalk after removal of the polyp head. The polyp head was removed by suction. Excess air was evacuated from the colon. The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition. Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN: ,Histologic evaluation and CLO testing. I will contact the parents next week with biopsy results and further management plans will be discussed at that time.surgery, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,
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PROCEDURES:,1. Robotic-assisted pyeloplasty.,2. Anterograde right ureteral stent placement.,3. Transposition of anterior crossing vessels on the right.,4. Nephrolithotomy.,DIAGNOSIS:, Right ureteropelvic junction obstruction.,DRAINS:,1. Jackson-Pratt drain times one from the right flank.,2. Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1. Renal pelvis.,2. Kidney stones.,INDICATIONS: ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries. Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL: ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out. After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated. Great care was taken to pad all pressure points and a right arm hanger was used. The patient was flexed slightly, and a kidney rest was used. Sequential compression devices were also placed. Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine. Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test. A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas. Next, a 12-mm camera port was placed near the umbilicus. The camera was inserted, and no bowel injury was seen. Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed. The robot was docked and the instruments passed through respective checks. Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially. Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum. At this point, the right kidney was in clear view, and the fascia was entered. Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection. It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole. These arteries were dissected carefully and vessel loops were applied. Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out. The pyelotomy was extended so that the renal collecting system could be directly inspected. Sequentially, each major calyx was inspected under direct vision and irrigated. A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient. At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis. The proximal ureter was spatulated using cold scissors. Next, redundant renal pelvis was excised using cold scissors and sent for permanent section. We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion. 3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis. Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures. Before final stitches were placed, a 6x28 ureteral stent was placed anterograde. This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter. This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision. Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures. Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis. Good pulsation was verified by direct vision proximal and distal to these pexy sutures. Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum. Hemostasis appeared excellent at this point. There was no obvious urine extravasation. At this time, the procedure was terminated. The robot was undocked. Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion. Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this. Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision. The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.surgery, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,
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REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week. The patient has also been on high-dose prednisone for an urticarial rash. The patient was admitted because of persistent high fevers without a clear-cut source of infection. She had been having temperatures of up to 103 for 8-10 days. She had been seen at Alta View Emergency Department a week prior to admission. A workup there including chest x-ray, blood cultures, and a transthoracic echocardiogram had all remained nondiagnostic, and were normal. Her chest x-ray on that occasion was normal. After the patient was seen in the office on August 10, she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital. Studies done at Cottonwood: CT scan of the chest, abdomen, and pelvis. Results: CT chest showed mild bibasilar pleural-based interstitial changes. These were localized to mid and lower lung zones. The process was not diffuse. There was no ground glass change. CT abdomen and pelvis was normal. Infectious disease consultation was obtained. Dr. XYZ saw the patient. He ordered serologies for CMV including a CMV blood PCR. Next serologies for EBV, Legionella, Chlamydia, Mycoplasma, Coccidioides, and cryptococcal antigen, and a PPD. The CMV serology came back positive for IgM. The IgG was negative. The CMV blood PCR was positive, as well. Other serologies and her PPD stayed negative. Blood cultures stayed negative.,In view of the positive CMV, PCR, and the changes in her CAT scan, the patient was taken for a bronchoscopy. BAL and transbronchial biopsies were performed. The transbronchial biopsies did not show any evidence of pneumocystis, fungal infection, AFB. There was some nonspecific interstitial fibrosis, which was minimal. I spoke with the pathologist, Dr. XYZ and immunopathology was done to look for CMV. The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection. The patient was started on ganciclovir once her CMV serologies had come back positive. No other antibiotic therapy was prescribed. Next, the patient's methotrexate was held.,A chest x-ray prior to discharge showed some bibasilar disease, showing interstitial infiltrates. The patient was given ibuprofen and acetaminophen during her hospitalization, and her fever resolved with these measures.,On the BAL fluid cell count, the patient only had 5 WBCs and 5 RBCs on the differential. It showed 43% neutrophils, 45% lymphocytes.,Discussions were held with Dr. XYZ, Dr. XYZ, her rheumatologist, and with pathology.,DISCHARGE DIAGNOSES:,1. Disseminated CMV infection with possible CMV pneumonitis.,2. Polymyositis on immunosuppressive therapy (methotrexate and prednisone).,DISCHARGE MEDICATIONS:,1. The patient is going to go on ganciclovir 275 mg IV q.12 h. for approximately 3 weeks.,2. Advair 100/50, 1 puff b.i.d.,3. Ibuprofen p.r.n. and Tylenol p.r.n. for fever, and will continue her folic acid.,4. The patient will not restart for methotrexate for now.,She is supposed to follow up with me on August 22, 2007 at 1:45 p.m. She is also supposed to see Dr. XYZ in 2 weeks, and Dr. XYZ in 2-3 weeks. She also has an appointment to see an ophthalmologist in about 10 days' time. This was a prolonged discharge, more than 30 minutes were spent on discharging this patient.general medicine, fever of unknown origin, blood cultures, transbronchial biopsies, infection, cmv, admission, illness, interstitial, fever, serologies, chest, nondiagnostic, methotrexate
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SUBJECTIVE:, This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit. After this occurred several times, they stopped giving him carrots. Last week, he ate some celery and the same thing happened. They had not given him any of that since. He eats other foods without any apparent pain or vomiting. Bowel movements are normal. He does have a history of reactive airway disease, intermittently. He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:, He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs: Weight: 31.5 pounds, which is an increase of 2.5 pounds since May. Temperature is 97.1. He certainly appears in no distress. He is quite interested in looking at his books.,Neck: Supple without adenopathy.,Lungs: Clear.,Cardiac: Regular rate and rhythm without murmurs.,Abdomen: Soft without organomegaly, masses, or tenderness.,ASSESSMENT:, Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.,PLAN:, I talked with mother about this. Certainly, it does not suggest any kind of an allergic reaction, nor obstruction. At this time, they will simply avoid those foods. In the future, they may certainly try those again and see how he tolerates those. I did encourage a wide variety of fruits and vegetables in his diet as a general principle. If worsening symptoms, she is welcome to contact me again for reevaluation.soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots,
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PROCEDURE: ,Direct-current cardioversion.,BRIEF HISTORY: ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and this is persistent. Therefore, he came in for cardioversion today. He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices. After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s. He tolerated it well. He will be observed for couple hours and discharged home later today. He will continue on his current medications. He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation.surgery, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,
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INDICATION:, Prostate Cancer.,TECHNIQUE:, 3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections.,FINDINGS:, There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull. The uptake in the remainder of the skeleton is within normal limits. The kidneys image normally. There is increased activity in the urinary bladder suggesting possible urinary retention.,CONCLUSION:,1. Focus of abnormal increased tracer activity overlying the right parietal region of the skull. CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2. There is probably some degree of urinary retention.,urology, prostate cancer, technetium, whole body, urinary retention, bone scan, radionuclide,
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HISTORY OF PRESENT ILLNESS:, This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was hard with blood in it. Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it. No history of fever, no diarrhea, no history of easy bruising. Excessive bleeding from minor cut. He has been slightly fussy.,PAST MEDICAL HISTORY: ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:, Regular table food, 24 ounces of regular milk. He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:, Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000. Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3. Albumin 3.3. AST 56 and ALT 26. CRP less than 0.3. Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute. Weight 9.6 kilogram.,GENERAL: He is alert and active child in no apparent distress.,HEENT: Atraumatic and normocephalic. Pupils are equal, round and reactive to light. Extraocular movements, conjunctivae and sclerae fair. Nasal mucosa pink and moist. Pharynx is clear.,NECK: Supple without thyromegaly or masses.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Soft and nondistended. Bowel sounds positive. No mass palpable.,GENITALIA: Normal male.,RECTAL: Deferred, but there was no perianal lesion.,MUSCULOSKELETAL: Full range of movement. No edema. No cyanosis.,CNS: Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding. Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:, To proceed with Meckel scan today. If Meckel scan is negative, we will consider upper endoscopy and colonoscopy. We will start colon clean out if Meckel scan is negative. We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg. Monitor hemoglobin.nan
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ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:, Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.discharge summary, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin
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XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ 07018,Re:orthopedic, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger,
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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. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.,2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL: ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.,2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.,2. Mild hypertensive cardiomyopathy with an EF of 48%.,3. Poor exercise capacity due to cardiovascular deconditioning.,4. Suboptimally controlled blood pressure on today's exam.cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia
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SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above. No fevers, no headaches, no shortness of breath currently. No chest pain or tightness. No abdominal pain, no heartburn, no constipation, diarrhea or dysuria. Occasional stress incontinence. No muscle or joint pain. No concerns about her skin. No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married. She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.,General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.,HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest: Clear to auscultation bilaterally.,Cardiovascular: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.,Extremities: Without cyanosis or edema.,Skin: Without abnormalities.,Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.,Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1. Asthma. Seems to be worse than in the past. She is just using her Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs p.o. b.i.d. May need to increase the dose. She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary. May also need to consider Singulair. She is to call me if she is not improving. If her shortness of breath worsens she is to call me or go into the emergency department. We will plan on following up for reevaluation in one month.,2. Allergic rhinitis. We will plan on restarting Allegra and Flonase daily for the time being.,3. Premenstrual dysphoric disorder. She may have some perimenopausal symptoms. We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4. Hematuria. Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing. She does have some frequent dysuria but is not having it currently.,5. Cervical dysplasia. Pap smear is taken. We will notify the patient of results. If normal we will go back to yearly Pap smear. She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.nan
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TITLE OF OPERATION:, Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:, 900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid. No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:, After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. No active bleeding was noted. No evidence of ectopic pregnancy was noted. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The sponge on a sponge stick was removed from the vagina. The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.surgery, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,
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EXAM: , MRI of lumbar spine without contrast.,HISTORY:, A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1: Central canal, neural foramina are patent.,L4-L5: Central canal, neural foramina are patent.,L3-L4: Central canal, neural foramen is patent.,L2-L3: Central canal, neural foramina are patent.,L1-L2: Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.neurology, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine
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PREOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,POSTOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,PROCEDURE:, CPT code 57307 - Closure of rectovaginal fistula, transperineal approach.,MATERIAL FORWARDED TO THE LABORATORY FOR EXAMINATION:, Includes fistula tract.,ESTIMATED BLOOD LOSS:, 25 mL.,INDICATIONS:, The patient is a 27-year-old morbidly obese gravida three, para one, who was seen in consultation from Dr. M's office, in the office of Chattanooga GYN Oncology on 01/12/06 regarding an obstetrically related rectovaginal fistula, dating from 1998. She had an episioproctotomy associated with the birth of her seven pound son in 1998 and immediately noted the spontaneous loss of gas and stool. She had her fistula repaired by Dr. R in 2000 and did well for approximately one year, without complaint, when she again noted the spontaneous loss of stool and gas from her vagina. She has partial control if her stools are formed, but she has no control of her gas. She is a type 2 diabetic, with poorly controlled blood sugars at times, however, her diabetes has been fairly well controlled of late.,FINDINGS AT THE TIME OF SURGERY:, She had a 1 cm fistulous tract, approximately 4 cm proximal to the vaginal introitus. This communicated directly with the low rectal vault. She had good rectal sphincter tone and a very thin perineal body. The fistulous tract was excised completely and intact. The underlying rectal mucosa was closed with chromic and the perineal body was reinforced and reconstructed. At the completion of the procedure, the repair is watertight, there were no other defects.,DESCRIPTION OF THE OPERATION:, The patient was taken to the operating room where she underwent general endotracheal anesthesia. She was then placed in the lithotomy position using candy-cane stirrups. The vulva and vagina were prepped and the patient was draped. A lacrimal duct probe was used to define the fistulous tract and a transperineal incision was made. The rectovaginal septum was developed and with an index finger in the rectum, the rectovaginal septum was easily defined. The fistulous tract was isolated and using the lacrimal duct probe, it was completely isolated. Using electrocautery dissection on the pure cut mode, the rectal mucosa was entered in a circumferential fashion as was the vaginal mucosa. This allowed for removal of the fistulous tract intact, with both epithelial layers preserved. The perineum and rectum were irrigated vigorously and then the rectal mucosa was reapproximated with a running stitch of number 4-0 chromic. The rectal vault was distended with saline and the repair was watertight. The defect was irrigated, suctioned, inspected and found to be free of clot, blood or debris. The perineal body was reconstructed with reapproximation of the levator muscles, using a series of interrupted horizontal mattress stitches of number 2-0 Vicryl. This allowed for excellent restoration of the perineal body. After this was accomplished, the defect was once again irrigated, suctioned, inspected, and found to be free of clot, blood or debris. The vaginal defect was closed with a running locking stitch of number 2-0 Vicryl and the perineal incision was closed with a subcuticular stitch of number 2-0 Vicryl. The patient was awakened and taken to the recovery room in stable condition, after having tolerated the procedure well.surgery, transperineal approach, fistula tract, fistula, rectovaginal, septum, lacrimal duct, probe, candy-cane, perineal, closure of rectovaginal fistula, rectal mucosa, perineal body, fistulous tract, rectovaginal fistula, transperineal, fistulous, rectal,
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PREOPERATIVE DIAGNOSES: ,1. Chronic eustachian tube dysfunction.,2. Retained right pressure equalization tube.,3. Retracted left tympanic membrane.,4. Dizziness.,POSTOPERATIVE DIAGNOSES:,1. Chronic eustachian tube dysfunction.,2. Retained right pressure equalization tube.,3. Retracted left tympanic membrane.,4. Dizziness.,PROCEDURE:,1. Removal of the old right pressure equalizing tube with placement of a tube. Tube used was Santa Barbara.,2. Myringotomy with placement of a left pressure equalizing tube. The tube used was Santa Barbara.,ANESTHESIA:, General.,INDICATION: , This is a 98-year-old female whom I have known for several years. She has a marginal hearing. With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly. So, we have kept sets of tubes in her ears at all times. The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed. There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia. Mask airway was used. IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant. In the same area, a small Santa Barbara tube was placed. This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated. Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis. Anterior, inferior incision was made. Tympanic membrane bounced back to neutral position. A Santa Barbara tube was cut to the 80% of the original length and placed in the hole. Ciprofloxacin drops were placed in the ear. Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:, None.,DISPOSITION:, To PACU in a stable condition.nan
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1354 }
Her past medical history includes a presumed diagnosis of connective tissue disorder. She has otherwise, good health. She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically. She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye. Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD. She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS. Intraocular pressures are 13 OU and by applanation. Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes. Gonioscopy showed normal anterior segment angle morphology in both eyes. She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes. Conjunctivae were quite, OU. Cornea were clear in both eyes. The anterior chamber is deep and quiet, OU. She has clear lenses, which are in good position, OU. Dilated fundus exam shows moderately optically clear vitreous, OU. The optic nerves are normal in size. The cup-to-disc ratios were approximately 0.4, OU. The nerve fiber layers are excellent, OU. The macula, vessels, and periphery were normal in both eyes. No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous. She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur. Otherwise, I can see her in 1 to 2 years.consult - history and phy., systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1355 }
PREOPERATIVE DIAGNOSIS:, Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE: ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The right upper extremity was then prepped and draped in standard surgical fashion. A small incision was made at the tip of the olecranon. Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. This was changed for a 0.79 K-wire. This was driven up to the fracture site. The fracture was manually reduced and then the K-wire passed through the distal segment. This demonstrated adequate fixation and reduction of both bones. The pin was then cut short. The fracture site and pin site was infiltrated with 0.25% Marcaine. The incision was closed using 4-0 Monocryl. The wounds were cleaned and dried. Dressed with Xeroform, 4 x 4. The patient was then placed in a well-moulded long-arm cast. He tolerated the procedure well. He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. X-rays of the right forearm will be taken. The patient may need additional mobilization time. Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. Intraoperative findings were relayed to the parents. All questions were answered.surgery, closed reduction, pinning, forearm refracture, fracture site, arm cast,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1356 }
PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room.urology, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1357 }
INDICATION FOR OPERATION:, Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:, Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:, After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner. Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture. Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion. Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally. The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar. We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal. The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs. On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof. The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate. It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position. The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place. Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place. The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum. The wounds were irrigated out. A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings. The patient tolerated the procedure well and did receive blood transfusions.surgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1358 }
PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. The preparation was poor, but mucosa was visible after lavage and suction. Small lesions might have been missed in certain places, but no large lesions are likely to have been missed. The mucosa was normal, was visualized. In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing. Biopsies were taken from the rectal wall to look for microscopic changes. The anal sphincter was considerably relaxed, with no tone and a gaping opening. The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum. No contraindications to consideration of a repair of the prolapse.surgery, olympus, colonoscope, bowel habits, colonic mucosa, colonic, rectum, rectal, cecum, mucosa, colonoscopy,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1359 }
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 gas and Mom has been using Mylicon drops which are helpful. She is burping well, hiccuping, sneezing and burping appropriately. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing. Delivery at Newton Medical Center at 39 weeks, 5 days gestation. Birth weight was 3160 g. Length 49.5 cm. Head circumference 33 cm. Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1. Infant did well after delivery and was dismissed to home with Mom the following day. No other hospitalizations. No surgeries.,ALLERGIES: , None.,MEDICATIONS:, Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family. History of cancer and asthma on the paternal side of the family. Mom unsure of what type of cancer.,SOCIAL HISTORY:, Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas. Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn. There is no smoking in the home. Family does have one pet dog in home.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs: Weight 7 pounds, 1-1/5 ounces. Height 21 inches. Head circumference 35.8 cm. Temperature 97.7.,General: Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT: Atraumatic, normocephalic. Anterior fontanel soft and flat. Pupils equal, round and reactive. Sclerae clear. Red reflex present bilaterally. TMs clear bilaterally. Oropharynx: Mucous membranes moist and pink.,Neck: Supple, no lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No masses or organomegaly. Healing umbilicus.,GU: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis. Some increased pigment over the sacrum.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule. Gave two week well-child check handout to Mom. Plan follow up for the one month well-child check or as needed for acute care. Mom will call for feeding problems, breathing problems or fever. Otherwise, plan to see at one month.nan
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1360 }
INFORMANT:, Dad on phone. Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY: ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis. All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done. The patient was put on ampicillin and cefotaxime. Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime. The patient was n.p.o. when he came in. He was on 3/4 L of oxygen. According to the note, it conveyed that he had some subcostal retractions. On arriving here, baby looks very healthy. He has no subcostal retractions. He is not requiring any oxygen and he is positive for urine and stool. The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile. ED called that case is a direct admit.,REVIEW OF SYSTEMS: ,The patient supposedly had fever, some weight loss, poor appetite. The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria. According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color. He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low. Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:, None.,HOSPITALIZATIONS:, Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY: ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications. Hospital stay 24 hours. Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:, None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: ,Lives with mom and dad. Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog. They usually visit to a ranch, but not recently. No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:, No allergies.,DIET:, Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS: Weight 3.725 kg.,GENERAL: Alert and comfortable and sleeping.,SKIN: No rash.,HEENT: Intact extraocular movements. PERRLA. No nasal discharge. No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK: Soft, nontender, supple.,CHEST: CTAP.,GI: Bowel sounds present. Nontender, nondistended.,GU: Bilaterally descended testes.,BACK: Straight.,NEUROLOGIC: Nonfocal.,EXTREMITIES: No edema. Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:, As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000. Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5. Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4. Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal. UA and LP results are pending. Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative. We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime. The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis. These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient. He does not need any further workup.,GASTROINTESTINAL: nan
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1361 }
SUBJECTIVE: ,The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU. Manifest refraction does not improve this. There is no afferent pupillary defect. Visual fields are grossly full to hand motions. Intraocular pressure measures 17 mm in each eye. Slit-lamp examination is significant for clear corneas OU. There is early nuclear sclerosis in both eyes. There is a sheet like 1-2+ posterior subcapsular cataract on the left. Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN: ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting. Cataracts are present in both eyes. I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained. This information was conveyed with the use of a translator.,ophthalmology, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1362 }
PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED: ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding. An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm. The uterine cavity was smooth upon curettage. Curettings were fairly copious. Sounding depth was 8 cm.,PROCEDURE:, The patient was brought to the Operating Room with an IV in place. The patient was given a general anesthetic and was placed in the lithotomy position. Examination under anesthesia was completed with findings as noted. She was prepped and draped and a speculum was placed into the vagina. ,Tenaculum was placed on the cervix. The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus. The endocervical canal was dilated without difficulty to a size 16 French dilator. A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity. No additional tissue was obtained. Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.surgery, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1363 }
PROCEDURE PERFORMED:,1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS: ,1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.,2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.,3. The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1. Left ventricular dysfunction with ejection fraction of 10% to 15%.,2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN: ,1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2. Hydration.,3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.surgery, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1364 }
PREOPERATIVE DIAGNOSIS:, Desire for sterility.,POSTOPERATIVE DIAGNOSIS:, Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped. Then, 1% lidocaine was used for anesthesia. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas. A segment about 3 cm in length was dissected out. It was clipped proximally and distally, and then the ends were cauterized after excising the segment. Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic. The identical procedure was performed on the contralateral side. He tolerated it well. He was discharged from the surgical center in good condition with Tylenol with Codeine for pain. He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead. Call if there are questions or problems prior to that time.surgery, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1365 }
HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.office notes, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress
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PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3. No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1. Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2. Total laminectomy C3, C4, C5, and C6.,3. Excision of scar tissue.,4. Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:, 1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:, Less than 250 cc.,INDICATIONS FOR THE OPERATION: ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression. Last surgery consisted of four-level decompression on 08/28/06. The patient continued to complain of posterior neck pain radiating to both trapezius. Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis. It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial. Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation. Operation and expected outcome risks and benefits were discussed with him prior to the surgery. Risks include but not exclusive of bleeding and infection. Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection. There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord. This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma. There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis. This too may require return to the operating room for evacuation of said pseudomeningocele and repair. The patient understood the risk of the surgery. I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring. The SSEPs were normal, and the EMGs were silent during the entire case. After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support. Shave was then carried out over the occipital and suboccipital region. All pressure points were padded. I proceeded to mark the hypertrophic scar for excision. This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar. Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified. There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina. With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery. There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel. By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7. There was significant epidural bleeding, which was carefully coagulated. At two points, I had to pack this with small pieces of Gelfoam. After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage. Area was irrigated with saline and bacitracin and then lined with Tisseel. The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch. The patient was extubated and transferred to recovery.nan
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CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY: ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable.,GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact.,NECK: No lymphadenopathy or JVD.,HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs.,LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi.,ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted.,GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES: No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:, Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.nan
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PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,POSTOPERATIVE:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,4. Delivery of a viable female, weight 5 pound, 14 ounces. Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:, Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS: ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction. The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department. The patient was then repositioned, prepped and draped in a slight left lateral tilt. Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in transverse fashion. Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique. The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. Presenting part was vertex, the head was delivered, followed by the remaining portion of the body. The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. Cord pH blood and cord blood was obtained. The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. This area was then irrigated. Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center. Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl. Skin edges reapproximated with sterile staples. Sterile dressing was applied. The uterus was evacuated of any remaining clots vaginally. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.obstetrics / gynecology, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine
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CC:, Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:, None.,ROS: , As above. Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS. He is in no apparent distress. ,Vital Signs: BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT: No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion. Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. No other trauma noted. No septal hematoma. No other facial bony tenderness. ,Neck: Nontender ,Chest: Breathing comfortably; equal breath sounds. ,Heart: Regular rhythm.,Abd: Benign.,Ext: No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro: Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal. ,COURSE IN THE ED:, Patient arrived and was placed on monitors. An IV had been placed in the field and labs were drawn. X-rays of the C spine show no fracture and I've removed the C-collar. The lacerations were explored and no foreign body found. They were irrigated and closed with simple interrupted sutures. Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine. The blood alcohol returned at 0.146. A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.general medicine, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,
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PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1. Repair of cleft soft palate, CPT 42200.,2. Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table. After anesthesia was administered, time out was taken to ensure correct patient, procedure, and site. The face was prepped and draped in a sterile fashion. The right ear tag was examined first. This was a small piece of skin and cartilaginous material protruding just from the tragus. The lesion was excised and injected with 0.25% bupivacaine with epinephrine and then excised using an elliptical-style incision. Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus. After this was done, the wound was cauterized and then closed using interrupted 5-0 Monocryl. Attention was then turned towards the palate. The Dingman mouthgag was inserted and the palate was injected with 0.25% bupivacaine with epinephrine. After giving this 5 minutes to take effect, the palate was incised along its margins. The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle. Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline. The Z-plasties were then designed, so there would be opposing Z-plasties from the nasal mucosa compared to the oral mucosa. The nasal mucosa was sutured first using interrupted 4-0 Vicryl. Next, the muscle was reapproximated using interrupted 4-0 Vicryl with an attempt to overlap the muscle in the midline. In addition, the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate. Following this, the oral layer of mucosa was repaired using an opposing Z-plasty compared to the nasal layer. This was also sutured in place using interrupted 4-0 Vicryl. The anterior and posterior open edges of the palatal were sewn together. The patient tolerated the procedure well. Suction of blood and mucus performed at the end of the case. The patient tolerated the procedure well.,IMMEDIATE COMPLICATIONS: , None.,DISPOSITION:, In satisfactory condition to recovery.surgery, repair, tragus, oral mucosa, nasal mucosa, ear tag, soft palate, palate, cleft, soft
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PREOPERATIVE DIAGNOSIS:, Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:, Left ovarian lesion.,PROCEDURE PERFORMED: ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,FINDINGS:, The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled. There were a few calcifications on the surface of the mass. The right ovary and fallopian tube appeared normal. There was no evidence of endometriosis. The uterus appeared normal in size. There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm. She does complain of minimal discomfort. Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position. A 1 cm skin incision was made in the infraumbilical vault. While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated. This was done using appropriate flow and volume of CO2. The #11 step trocar was then placed without difficulty. The above findings were confirmed. A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization. Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall. Both #12 step ports were done under direct visualization. Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating. The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision. The skin was extended around this incision and the fascia was extended using the Mayo scissors. The specimen was removed intact in the Endocatch bag through this site. Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic. All the port sites were hemostatic as well. The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated. Steri-Strips were placed on each of the incisions. The patient tolerated the procedure well. Sponge, lap, and needle count were x2. She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.obstetrics / gynecology, salpingo-oophorectomy, ovarian lesion, adnexal mass, salpingo oophorectomy, abdominal wall, intact, adnexal, laparoscopy, mass,
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INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.hematology - oncology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: 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 transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.orthopedic, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness
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PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Ruptured appendicitis.,PROCEDURE:, Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:, This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers. The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's abdomen was prepped and draped in usual sterile fashion. A periumbilical incision was made. The fascia was incised. Peritoneal cavity entered bluntly. A 10-mm trocar and scope was passed. Peritoneal cavity was insufflated. Five-mm ports placed in left lower and hypogastric areas. On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus. We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site. We irrigated and suctioned out the right lower and pelvic areas. We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips. The patient was extubated in the operating table and taken back to recovery room. The patient tolerated the procedure well.surgery, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy,
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HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2. Biophysical profile (BPP) score 8/8.obstetrics / gynecology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,
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HISTORY:, This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction. After catheterization, the patient underwent cystoscopy on 4/13. On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved. Final diagnosis was adenocarcinoma of the prostate. Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:, None,PROCEDURES:,Cystoscopy: Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate: 45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.urology, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma,
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ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:, Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.allergy / immunology, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin
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PAST MEDICAL CONDITION:, None.,ALLERGIES:, None.,CURRENT MEDICATION:, Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:, The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:, The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bending to the right was decreased. Side bending to the left was within normal limits. Rotation and extension to the right side was causing increasing pain. Extension and side bending to the left was within normal limits without significant pain on the left side. While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°. There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. In supine position, straight leg was negative in the LLE and also negative on the RLE. Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. Medial hamstring reflex was 2+/4 on both hamstrings as well. On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:, I had the opportunity to review Dr. XYZ's medical records. Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December. Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal. The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:, The patient has an impairment based on AMA Guides Fifth Edition and it is permanent. The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck. Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. The patient also has increase in back pain with lumbar flexion and rotational movement to the right side. With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. Therefore, the patient is assigned 8% impairment of the whole person. We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide. Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury. In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI. In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,orthopedic, rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,
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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 appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints.,REVIEW OF SYSTEMS:, CONSTITUTIONAL: No fever or chills. No fatigue or weakness. HEENT: No headache. No neck pain. No eye pain or vision change. No rhinorrhea. No sinus congestion, pressure, or pain. No sore throat. No throat swelling. The patient does have the toothache on the left lower side that radiates towards his left ear as previously described. The patient does not have ear pain or hearing change. No pressure in the ear. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath. GASTROINTESTINAL: No nausea or vomiting. No abdominal pain. MUSCULOSKELETAL: No back pain. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No speech change. HEMATOLOGIC/LYMPHATIC: No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:, None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana. The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be healthy. The patient is calm, comfortable in no acute distress, looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctivae bilaterally. Nose, normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. Ears are normal without any sign of infection. No erythema or swelling of the canals. Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. MOUTH: The patient has a dental fracture at tooth #18. The patient states that the fracture is a couple of months old. The patient does not have any obvious dental caries. The gums are normal without any erythema, swelling, or evidence of infection. There is no fluctuance or suggestion of abscess. There is slight tenderness of the tooth #18. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion, or swelling. Mucous membranes are moist. Floor of the mouth is normal without any tenderness or swelling. No suggestion of abscess. There is no pre or post auricular lymphadenopathy either. NECK: Supple. Nontender. Full range of motion. No meningismus. No cervical lymphadenopathy. No JVD. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to the back, arms, or legs. The patient has normal use of the extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. No evidence of clinical intoxification. HEMATOLOGIC/LYMPHATIC: No lymphadenitis is palpated.,DIAGNOSES:,1. ACUTE LEFT JAW PAIN.,2. #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3. ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation. The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain. The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain. He was given precautions for drowsiness and driving with the use of this medication. The patient was also given a prescription for pen V. The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.dentistry, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,
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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 operating room and MAC anesthesia was administered. Next, the patient's chest and neck were prepped and draped in the standard surgical fashion. Lidocaine 1% was used to infiltrate the skin in the region of the procedure. Next a #18-gauge finder needle was used to locate the left subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle. This process was repeated. The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, the subcutaneous tunnel was created. The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff. A dilator and sheath were passed over the individual J wires. The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. The process was repeated. Both distal tips were noted to be in good position. The Tesio hemodialysis catheters were flushed and aspirated without difficulty. The catheters were secured at the cuff level with a 2-0 nylon. The skin was closed with 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition.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 quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1381 }
EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered.,The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis. Please see report above.nephrology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,
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PREPROCEDURE DIAGNOSIS:, Change in bowel function.,POSTPROCEDURE DIAGNOSIS:, Proctosigmoiditis.,PROCEDURE PERFORMED:, Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable. ,INDICATIONS:, The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is here for colonoscopy. He understands the risks and wishes to proceed. ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation. Digital rectal examination was performed, which showed no masses, and a boggy prostate. The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum. In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,
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CHIEF COMPLAINT:, Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:, A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema.,She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks.,PAST MEDICAL HISTORY:, Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:, She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis.,SOCIAL HISTORY:, The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California.,MEDICATIONS:, Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:, As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General: No fever, chills, or night sweats. Weight stable.,HEENT: No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes. No hearing changes or ear problems. No swallowing problems or mouth lesions.,Endocrine: Hypothyroidism but no polyuria or polydipsia. She watches her blood sugars. They have been doing quite well.,Respiratory: No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular: No chest pain or chest discomfort. No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI: As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better. She has had some irritable bowel syndrome and bowel abnormalities for years.,GU: No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. No vaginal bleeding or discharge.,Musculoskeletal: As above.,Hematological: She has had some anemia in the past.,Neurological: No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs: Weight is 164 pounds. Blood pressure: 140/64. Pulse: 72. Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General: A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT: Skull is normocephalic. TMs intact and shiny with good auditory acuity to finger rub. Pupils equal, round, reactive to light and accommodation with extraocular movements intact. Fundi benign. Sclerae and conjunctivae were normal.,Neck: No thyromegaly or cervical lymphadenopathy. Carotids are 2+ and equal bilaterally and no bruits present.,Lungs: Clear to auscultation and percussion with good respiratory movement. No bronchial breath sounds, egophony, or rales are present.,Heart: Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. PMI normal position. All pulses are 2+ and equal bilaterally.,Abdomen: Obese, soft with no hepatosplenomegaly or masses.,Breasts: No predominant masses, discharge, or asymmetry.,Pelvic Exam: Normal external genitalia, vagina and cervix. Pap smear done. Bimanual exam shows no uterine enlargement and is anteroflexed. No adnexal masses or tenderness. Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities: The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well. No real erythema. There is no real swelling of the knees. No new pedal edema.,Lymph nodes: No cervical, axillary, or inguinal adenopathy.,Neurological: Cranial nerves II-XII are grossly intact. Deep tendon reflexes are 2+ and equal bilaterally. Cerebellar and motor function intact in all extremities. Good vibratory and positional sense in all extremities and dermatomes. Plantar reflexes are downgoing bilaterally.,LABORATORY: ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. Urinalysis is within normal limits. Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1. Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. I think we need to look at this more closely.,2. Diarrhea that seems to have resolved. Whether this is related to the above is unclear.,3. Diabetes mellitus type II, really fairly well controlled.nan
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PREOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy with decompression C6-C7.,2. Arthrodesis with anterior interbody fusion C6-C7.,3. Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4. PEEK implant 7 mm.,5. Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS: ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS: ,Round French 10 JP drain.,SPECIMENS,: None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:, This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped. The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07. This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow. She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear. She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level. Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level. Operation, expected outcome, risks, and benefits were discussed with her. Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma. There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function. Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics. However, the patient may develop deeper-seated infection, which may require return to the operating room. Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft. There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery. There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid. There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. There is also the risk of pseudoarthrosis and hardware failure. She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case. The EMGs were silent and there was no evidence of any stimulation. After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension. The head was supported on a foam doughnut. The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side. A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm. The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision. The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles. Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath. The prevertebral fascia was identified and cut sharply. A localizing x-ray verified the marker to be at the C6-C7 interspace. Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7. Self-retaining retractor was then laid out. The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr. The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7. There was note of a new osteophyte on the left C6-C7 foramen. This was carefully drilled down. After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders. They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam. After this was completed, Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant was then tapped into placed after its interior was packed with Vitoss. The plate was then applied and secured in place with four 12 x 4.7 mm screws. Irrigation of the area was done. A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis. The wound was reinforced with Dermabond. The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site. C-collar was placed and the patient was transferred to Recovery after extubation.nan
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The patient made some progress during therapy. She accomplished two and a half out of her five short-term therapy goals. We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits. The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently. The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect. She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently. Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect. The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9. Her last session occurred on 01/09/09. She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.speech - language, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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XYZ, M.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC. The patient is being referred for evaluation of diabetic retinopathy. The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20. The vision in the left eye is 20/20 uncorrected. Applanation pressures are normal at 17 mmHg bilaterally. Visual fields are full to count fingers OU and there is no relative afferent pupillary defect. Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU. On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally. The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time. We recommended him to have his eyes dilated once a year. I have advised him to follow up with you for his regular check-ups. Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,ophthalmology, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic,
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PREOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2. Microscope.,3. Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4. Eagle titanium plate from C3 to C6.,5. Jackson-Pratt drain placement.,6. Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: ,None.,COUNTS: , Correct.,SPECIMENS SENT: ,None.,CLINICAL HISTORY: ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling. He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy. I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly. The patient had worst disease at level C3-C4, C4-C5, and C5-C6. The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side. I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall. Conservative management was not an option. The patient was preoped and consented, and was medically cleared. I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family. The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient. An informed consent was obtained from the patient as such. He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the OR, intubated, and given a general anesthetic. Intubation was done under C-spine precautions. The patient received preoperative vancomycin and Decadron. He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped. All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine. Prominent osteophyte at C5-C6 was noted, lesser at C4-C5. Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went. I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord. Worst findings at C3-C4 followed C5-C6 and then C4-C5. Excellent thecal sac decompression was achieved and foraminal decompression was also achieved. With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant. This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time. I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis. This took literally half-an-hour to an hour and added to the complexity and difficulty of this case. Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution. These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position. Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6. Fourteen millimeter screws were used; all the screws were tightened and torqued. The patient's bone quality was poor, but the screws did torque appropriately. I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar. Decision was made to start the closure. So, I closed the platysma with 3-0 Vicryl and used staples for the skin. A simple Primapore or Medpore dressing was applied. The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side. He had done well from the surgery. Blood loss was 350 cc. All instrument, needle, and sponge counts were correct. No complications, no change in intraoperative monitoring. No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis. The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity. I will keep him on Decadron and keep the collar on. I do not think there is need for halo rest. We will be obtaining formal C-spine films in the morning. Prognosis is guarded but favorable at this time.nan
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EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis.nephrology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,
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PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed. The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD. The patient is fed by mouth and also with nasogastric enteral feeding supplements. She has had an __________ cough and relatively disinterested in oral intake for the past month. She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted. Based on the history, it is quite possible this coin has been there close to a month. She is brought to the operating room now for attempted removal. I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time. Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location. There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive. The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia. She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications. After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism. A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view. This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen. At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps. I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved. The patient tolerated the procedure well. There were no intraoperative complications. There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.surgery, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,
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EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.podiatry, three views, radiopaque, fractures, foot trauma
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PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:, Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1. Left neck mass biopsy.,2. Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:, After obtaining an informed, the patient was taken to the operating room where a time-out process was followed. Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room. Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation. The neck was prepped and draped in the usual fashion. I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap. Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass. The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck. A wedge sample was sent to Pathology for frozen section. At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen. Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements. This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface. There, there were some attachments to branches of the external carotid artery, which had to be suture ligated. At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck. This worked out quite nicely. The external jugular vein was out of the way, so initially we did not deal with it. We proceeded to tackle the area III and extended into II-A. When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise. Also, I felt that the submaxillary gland was enlarged. At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle. At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination. Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen. Hemostasis was revised and found to be adequate. The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap. The flap was replaced in its position. A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin. I would like to mention that also the facial vein was excised and the external jugular vein was ligated. It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it. A pressure dressing was applied.,The patient tolerated the procedure well. Estimated blood loss was no more than 100 mL. The patient was extubated in the operating room and sent for recovery.surgery, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein,
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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-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.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,
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PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63. Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA. The patient had a prostate biopsy with T2b disease, Gleason 6. Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed. The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure. The patient was told that there could be other unexpected complications. The patient has history of urethral stricture. The patient was told about the risk of worsening of the stricture with radiation. Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient had SCDs on. The patient was given preop antibiotics. The patient had done bowel prep the day before. Transrectal ultrasound was performed. The prostate was measured at about 32 gm. The images were transmitted to the computer system for radiation oncologist to determine the dosing etc. Based on the computer analysis, the grid was placed. Careful attention was drawn to keep the grid away from the patient. There was a centimeter distance between the skin and the grid. Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate. A total of 24 needles was used. Careful attention was drawn to stay away from the urethra. Under longitudinal ultrasound guidance, all the seeds were placed. There were no seeds visualized in the bladder under ultrasound. There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position. Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy. Please note that the Foley catheter was in place throughout the procedure. Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter. The patient has had history of bulbar urethral stricture. Pictures were taken of the strictures in the pre-seed placement cysto time frame. We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in. At the end of the procedure, again cystoscopy was done, the entire bladder was visualized. The stricture was wide open. The prostate was slightly enlarged. The bladder appeared normal. There was no sheath inside the urethra or in the bladder. The cysto was done using 30-degree and 70-degree lens. At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed. The plan was for Foley to be left in place overnight since the patient has history of urethral strictures. The patient is to follow up tomorrow to have the Foley removed. The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure. The patient tolerated the procedure well.urology, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate,
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CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed "fidgety movements" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.nan
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SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.soap / chart / progress notes, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1396 }
INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit. The patient is appropriately immobilized using a customized immobilization device. Preliminary simulation films are obtained and approved by me. The patient is marked and transferred to the CT scanner. Sequential images are obtained and transferred electronically to the treatment planning software. Extensive analysis then occurs. The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition organs at risk are outlined. Appropriate doses are selected, both for the target, as well as constraints for organs at risk. Inverse treatment planning is performed by the physics staff under my supervision. These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.radiology, target volume, intensity modulated radiation therapy, simulationNOTE,: 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 transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
{ "dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40", "dataset_name": "medical-transcription-40", "id": 1397 }
PREOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1. Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2. Bilateral C6 nerve root decompression.,3. Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4. Bilateral C5 nerve root decompression.,5. Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6. Bilateral C4 nerve root decompression.,7. Harvesting of autologous bone from the vertebral bodies.,8. Grafting of allograft bone for creation of arthrodesis.,9. Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12. Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6. There was a herniated disk with cord compression and radiculopathy at C4-C5. C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels. Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives. He clearly understands and has no further questions and requests that I proceed.,PROCEDURE: ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease. Dissection was carried down through the platysma musculature and the anterior spine was exposed. The medial borders of the longus colli muscle were dissected free from their attachments to the spine. Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained. A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space. The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies. The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament. The ligament was incised and the underlying dura was exposed. I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen. There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact. However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right. The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5. I worked down through bony osteophytes and identified the posterior longitudinal ligament. The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces. The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen. The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it. Again the microscope was angled to the left side where similar decompression was achieved. Central decompression was achieved here where there was a moderate amount of spinal cord compression. This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space. Here there were large osteophytes projecting posteriorly against the cord. I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord. This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord. I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right. The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis. A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration. Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis. Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4. Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge. I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks. The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described. An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation. Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate. The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush. The holes were drilled and the screws were placed. Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6. All eight screws had good purchase. The locking screws were tightly applied. An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure. The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained. A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct. There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.nan
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EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,orthopedic, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons
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