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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1700
}
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PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.hematology - oncology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1701
}
|
TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1. AWAKE: Normal.,2. SLEEP: No activation.,3. CLINICAL EVENTS: None.,DESCRIPTION: , Approximately 27 hours of continuous 21-channel digital video EEG monitoring was performed. The waking background is unchanged from that previously reported. Hyperventilation produced no changes in the resting record. Photic stimulation failed to elicit a well-developed photic driving response.,Approximately five-and-half hours of spontaneous intermittent sleep was obtained. Sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION: ,This is normal video EEG monitoring for a patient of this age. No interictal epileptiform activity was identified. The patient had no clinical events during the recording. Clinical correlation is required.sleep medicine, electroencephalography, eeg monitoring, video eeg, seizures, eeg,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1702
}
|
CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.neurology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1703
}
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CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches. ,PMH: , None. ,MEDICATIONS: ,Tylenol for pain.,ALLERGIES:, None.,FAMILY HISTORY: , Grandmother died of cerebral aneurysm. ,ROS:, Negative.,PHYSICAL EXAM: ,Vital Signs: BP 102/60 P 70 RR 20 T 98.2 ,HEENT: Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,Neck: Supple without meningismus. ,Chest: Lungs clear; heart regular without murmur.,COURSE IN THE ED: , The patient was seen in the urgent care and examined. At this time, her photophobia and nausea make migraine highly likely. She is well appearing and we'll try Tylenol with codeine for her pain. One day off school and follow up with her primary doctor. ,IMPRESSION: , Migraine headache. ,PLAN: , See above.general medicine, photophobia, nausea, migraine headache, tylenol, migraine, headache,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1704
}
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PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1. Left abdominal flap 5 x 5 cm to left forearm.,2. Debridement of skin, subcutaneous tissue, muscle, and bone.,3. Closure of wounds, simple closure approximately 8 cm.,4. Placement of VAC negative pressure wound dressing.,INDICATIONS: , This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure.,OPERATIVE FINDINGS: , A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory.,DESCRIPTION OF PROCEDURE: , Under inhalational anesthesia, he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen, chest, and groin. He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure. Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them. In this fashion, simple closure was accomplished and its total length was approximately 8 cm. It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis. At this time, once we accomplished debridement and simple closure removing skin, subcutaneous tissue, muscle and bone as well as closing the arm, we could design our flap for the abdomen. The flap was designed as a slightly greater than 1:1 ellipse of skin from just below the costal margin. This was elevated at the level of the external oblique and then laid on the left forearm. The donor's site was closed using interrupted 4-0 Vicryl in the deep dermis and running subcuticular 4-0 Monocryl on the skin. Steri-Strips were applied. At this time, the flap was inset using again 4-0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap. The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition.surgery, abdominal flap, debridement, skin, subcutaneous tissue, muscle, bone, closure of wounds, vac, vac negative, upper extremity, closure, wounds, flap, extremity, amputation
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1705
}
|
CHIEF COMPLAINT:, Weak and shaky.,HISTORY OF PRESENT ILLNESS:, The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further, she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough, hemoptysis, dyspnea, and wheeze. She denies syncope, presyncope, or palpitations. Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:, She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:, She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:, Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:, She is a widow, lives alone. Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:, Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General: She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs: Blood pressure: 146/80. Pulse: 68. Weight: 147 pounds.,HEENT: Unremarkable.,Neck: Supple without JVD, adenopathy, or bruit.,Chest: Clear to auscultation.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft.,Extremities: No edema.,LABORATORY:, O2 sat 100% at rest and with exertion. Electrocardiogram was normal sinus rhythm. Nonspecific S-T segment changes. Chest x-ray pending.,ASSESSMENT/PLAN:,1. Dyspnea on exertion, uncertain etiology. Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors. We will have the patient sign a release of records so that we can review her previous history. Consider setting up for a stress test.,2. Hypertension, blood pressure is acceptable today. I am not certain as to what, if the patient’s is on any antihypertensive agents. We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3. History of diabetes. Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C. I have to obtain some further history and review records before proceeding with treatment recommendations.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1706
}
|
PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,surgery, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1707
}
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PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,TITLE OF OPERATION: ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where retrobulbar anesthesia was induced. The patient was then prepped and draped using standard procedure. A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12. The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome. The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed. The phacoemulsification was then instilled in the eye and a linear incision made in the lens. The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip. The remaining cortex was removed with an I&A. The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome. The folding posterior chamber lens was then inserted in the capsular bag and rotated into position. The remaining viscoelastic was removed from the eye with the I&A. The wound was checked for watertightness and found to be watertight. Tobramycin drops were instilled in the eye and a shield placed over it. The patient tolerated the procedure well.surgery, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1708
}
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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.obstetrics / gynecology, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1709
}
|
HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY: ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:, As an outpatient:,1. Lanoxin 0.125 mg, 1/2 tablet once a day.,2. Tramadol 50 mg p.o. q.i.d. as needed.,3. Verapamil 240 mg once a day.,4. Bumex 2 mg once a day.,5. ProAir HFA.,6. Atrovent nebs b.i.d.,7. Pulmicort nebs b.i.d.,8. Nasacort 55 mcg, 2 sprays daily.,9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11. Aldactone 25 mg p.o. daily.,12. Theo-24 200 mg p.o., 2 in the morning.,13. Zocor 40 mg once a day.,14. Vitamin D 400 units twice daily.,15. Levoxyl 125 mcg once a day.,16. Trazodone 50 mg p.o. q.h.s. p.r.n.,17. Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1. LEVAQUIN.,2. AZITHROMYCIN.,3. ADHESIVE TAPE.,4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY: ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY: ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS: ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA: ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1710
}
|
PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried. ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.surgery, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1711
}
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PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope. He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture. He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass. His mandible fracture was not noted initially. The patient also has a history of prostate cancer and a renal cell carcinoma. The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending. The patient later saw a local oral surgeon. He diagnosed his mandible fracture and advised him to seek treatment in Houston. He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago. The patient had significant discomfort and could eat foods and drink fluids with difficulty. Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position. Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion. The patient was then prepped and draped in a manner consistent with sterile procedures. A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible. A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue. A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible. Electrocautery as well as 4.0 silk ties were used for hemostasis. A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site. The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound. Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis. Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site. Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site. When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically. All the screws were also locking screws. Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline. The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin. A sterile dressing was then placed over the incision. The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs. Estimated blood loss is 125 mL.dentistry, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,
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{
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"dataset_name": "medical-transcription-40",
"id": 1712
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HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors. The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.hematology - oncology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: 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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{
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"dataset_name": "medical-transcription-40",
"id": 1713
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REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. The patient is unable to provide further history. The patient's son is at the bedside and confirmed his history. The patient was given IV antibiotics in the emergency room. He was also given some hydration.,PAST MEDICAL HISTORY:,1. History of CAD.,2. History of dementia.,3. History of CVA.,4. History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1. Ambien.,2. Milk of magnesia.,3. Tylenol.,4. Tramadol.,5. Soma.,6. Coumadin.,7. Zoloft.,8. Allopurinol.,9. Digoxin.,10. Namenda.,11. Zocor.,12. BuSpar.,13. Detrol.,14. Coreg.,15. Colace.,16. Calcium.,17. Zantac.,18. Lasix.,19. Seroquel.,20. Aldactone.,21. Amoxicillin.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care. No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is currently afebrile. Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL: The patient is awake. Not oriented x3, in no acute distress.,HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are dry.,NECK: Supple. No thyromegaly. No jugular venous distention.,HEART: Irregularly irregular, brady.,LUNGS: Clear to auscultation bilaterally anteriorly.,ABDOMEN: Positive normoactive bowel sounds. Soft. Tenderness in the suprapubic region without rebound.,EXTREMITIES: No clubbing, cyanosis or edema in upper and lower extremities.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1714
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PREOPERATIVE DIAGNOSIS: , Breast assymetry, status post previous breast surgery.,POSTOPERATIVE DIAGNOSIS: ,Breast assymetry, status post previous breast surgery.,OPERATION: , Capsulotomy left breast, flat advancement V to Y left breast for correction lower pole defect.,ANESTHESIA:, LMA.,FINDINGS AND PROCEDURE: ,The patient is a 35-year-old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast. The nipple inframammary fold distance is approximately 1.5 cm shorter than the fuller right breast. The patient has bilateral Mentor-Smooth round moderate projection jell-filled mammary prosthesis, 225 cc.,The patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance. She was then brought to the operating room and after satisfactory LMA anesthesia had been induced, the patient was prepped and draped in the usual manger. The patient received a gram of Kefzol prior to beginning the procedure. The previous inverted T-scar was excised down to the underlying capsule of the breast implant. The breast was carefully dissected off of the underlying capsule. Care being taken to preserve the vascular supply to the skin and breast flap. When the anterior portion of the breast was dissected free of the underlying capsule, the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle. A posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap. The lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2-0 Monocryl statures. Care was taken to avoid as much exposure of the implant, as well as damage to the implant. When the flap had been created and advanced, hemostasis was obtained and the area copiously irrigated with a solution of Bacitracin 50,000 units, Kefzol 1 g, gentamicin 80 mg, and 500 cc of saline. The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2-0 Biosyn. This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast. The remainder of the inverted T was closed with interrupted sutures of 3 and 2-0 Biosyn and the skin was closed with continuous suture of 5-0 nylon. Bacitracin and a standard breast dressing were applied.,The anesthesia was terminated and the patient was recovered in the operating room. Sponge, instrument, needle count reported as corrected. Estimated blood loss negligible.cosmetic / plastic surgery, capsulotomy, biosyn, breast, breast assymetry, kefzol, mentor-smooth, breast surgeries, flat advancement, inframammary fold, lower pole defect, mammary, mammary prosthesis, nipple, breast surgery, assymetry, inframammary, capsule
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{
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"dataset_name": "medical-transcription-40",
"id": 1715
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PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA: ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS: ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed. A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed. Two passes were made with the suction curettage. Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. After the procedure, the vulsellum tenaculum was removed. The cervix was seemed to be hemostatic. The weighted speculum was removed. The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure. After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size. It is now approximately eight to ten-week size. The patient was taken from the operating room in stable condition after she was cleaned. She will be discharged on today. She was given Methergine, Motrin, and doxycycline for her postoperative care. She will follow-up in one week in the office.surgery, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,
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{
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"dataset_name": "medical-transcription-40",
"id": 1716
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EXTERNAL EXAMINATION: , The autopsy is begun at 8:30 A.M. on May 24, 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wide silver expandable wristband on left wrist. A 1.5-inch wide tan belt with green stripes is cinched around the upper neck using the buckle. The opposite end of the belt is tied in a half-hitch knot, which was used to affix it to the crossbar in the closet where the body was found. ,The body is that of a normally developed white female measuring 67 inches and weighing 118 pounds, and appearing generally consistent with the stated age of twenty-six years. The body is cold and unembalmed. Lividity is fixed in the distal portions of the limbs. The eyes are open. The irises are brown and corneas are cloudy. Petechial hemorrhaging is present in the conjunctival surfaces of the eyes. The pupils measure 0.3 cm. The hair is dark blonde with lighter blonde highlights, wavy, layered and approximately 11 inches in length at the longest point. ,Removal of the belt revealed a ligature mark (known throughout this report as Ligature A) on the neck below the mandible. Ligature A is approximately 1.5 inches wide and encircles the neck in the form of a "V" on the anterior of the neck and an inverted "V" on the posterior of the neck, consistent with hanging. Minor abrasions are present in the area of Ligature A. Lack of hemorrhage surrounding Ligature A indicates this injury to be post-mortem. ,Upon removal of the victim's clothing, an odor of bleach was detected. Areas of the body were swabbed and submitted for detection of hypochlorite. Following removal of the shirt, a second ligature mark (known throughout this report as Ligature B) was observed on the victim's neck. The mark is dark red ligature and encircles the neck, crossing the anterior midline of the neck just below the laryngeal prominence. The width of the mark varies between 0.8 and 1cm and is horizontal in orientation. The skin of the anterior neck above and below the ligature mark shows petechial hemorrhaging. Ligature B is not consistent with the belt that caused Ligature A. The absence of abrasions associated with Ligature B, along with the variations in the width of the ligature mark, are consistent with a soft ligature, such as a length of fabric. No trace evidence was recovered from Ligature B that might assist in identification of the ligature used. ,The genitalia are that of an adult female and there is no evidence of injury. Pubic hair has been shaved in its entirety within six hours of death. Limbs are equal, symmetrically developed and show no evidence of injury. The fingernails are medium length and fingernail beds are blue. There are no residual scars, markings or tattoos.,INTERNAL EXAMINATION: ,HEAD--CENTRAL NERVOUS SYSTEM: ,Subsequent autopsy shows a broken hyoid bone. Hemorrhaging from Ligature B penetrates the skin and subdermal tissues of the neck. The brain weighs 1,303 grams and within normal limits. ,SKELETAL SYSTEM:, The hyoid bone is fractured. ,RESPIRATORY SYSTEM--THROAT STRUCTURES: ,The oral cavity shows no lesions. Petechial hemorrhaging is present in the mucosa of the lips and the interior of the mouth. Otherwise, the mucosa is intact and there are no injuries to the lips, teeth or gums. ,There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The hyoid bone, the thyroid, and the cricoid cartilages are fractured. ,The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable. ,CARDIOVASCULAR SYSTEM: ,The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present. ,GASTROINTESTINAL SYSTEM: ,The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,URINARY SYSTEM: ,The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions. ,FEMALE GENITAL SYSTEM: ,The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. There is evidence of recent sexual activity but no indications that the sexual contact was forcible. Vaginal fluid samples are removed for analysis. ,TOXICOLOGY: ,Sample of right pleural blood and bile are submitted for toxicologic analysis. Stomach contents are saved. ,SEROLOGY:, A sample of right pleural blood is submitted in the EDTA tube. Routine toxicologic studies were ordered.,LABORATORY DATA,CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:,Gram stain: Unremarkable,Culture: No growth after 72 hours,CEREBROSPINAL FLUID BACTERIAL ANTIGENS:,Hemophilus influenza B: Negative,Streptococcus pneumoniae: Negative,N. Meningitidis: Negative,Neiserria meningitidis B/E. Coli K1: Negative ,Drug Screen Results:,URINE SCREEN {IMMUNOASSAY} WAS NEGATIVE. ,Ethanol: 0 gm/dl, Blood (Heart),Ethanol: 0 gm/dl, Vitreous ,EVIDENCE COLLECTED:,1. One (1) white turtleneck sleeveless shirt, size Small. ,2. One (1) pair navy blue sweatpants, size Small.,3. Two (2) silver hoop earrings. ,4. One (1) silver bracelet.,5. Samples of Blood (type O+), Bile, and Tissue (heart, lung, brain, kidney, liver, spleen). ,6. Fifteen (15) swabs from various body locations, to be tested for presence of hypochlorite.,7. Eleven (11) autopsy photographs. nan
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"dataset_name": "medical-transcription-40",
"id": 1717
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PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.orthopedic, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,
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{
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"dataset_name": "medical-transcription-40",
"id": 1718
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PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:, Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY: ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting. He was referred to me for that reason to be treated under general anesthesia for his dental work. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. There are no contraindications to this procedure. He is healthy. His history and physical is in the chart.,PROCEDURE: ,The patient was brought to the operating room at 10:15 and placed in the supine position. Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined. A throat pack was then placed. Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite. Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite. Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite. Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary. This was done using ferric sulfate and zinc oxide eugenol. For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly. The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30. There was no blood loss.surgery, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries,
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{
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TITLE OF OPERATION:, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:, Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:, Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding. The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping. Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles. The patient also had a right subtemporal depression, which was full preoperatively. The entire old apparatus was dissected out. We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted. They were both inspected. No definite debris were seen. After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter. On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location. The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture. The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir. All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips. The patient tolerated the procedure well without complications. CSF was not sent off.neurosurgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal
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{
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"dataset_name": "medical-transcription-40",
"id": 1720
}
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PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,PROCEDURES,1. Anterior cervical discectomy, C3-C4, C2-C3.,2. Anterior cervical fusion, C2-C3, C3-C4.,3. Removal of old instrumentation, C4-C5.,4. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position. The neck was prepped and draped in the usual fashion for anterior cervical discectomy. A high incision was made to allow access to C2-C3. Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate. We placed in self-retaining retractors. With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5. After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal. In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4. We then placed the ABC 55-mm plate from C2 down to C4. These were secured with 16-mm titanium screws after excellent purchase. We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin. Blood loss was about 50 mL. No complication of the surgery. Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation. At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion
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{
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"dataset_name": "medical-transcription-40",
"id": 1721
}
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XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE: XXXX, XXXX ,MR#: 0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic. I appreciate you speaking with me while he was in clinic. He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side. His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration. They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially. I think he should stay on MiraLax for management of his bowels. I would also suggest that he be referred to Pediatric Gastroenterology for evaluation. If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic. If you have any questions, please feel free to contact me. ,Sincerely yours,letters, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology,
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{
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"dataset_name": "medical-transcription-40",
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REASON FOR VISIT: ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. He is currently at home and has left nursing home facility. He states that his pain is well controlled. He has been working with physical therapy two to three times a week. He has had no drainage or fever. He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed. He has no effusion noted. His range of motion is 10 to 105 degrees. He has no pain or crepitance. On examination of his right foot, he is nontender to palpation of the metatarsal heads. He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex. He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation. Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures. These appear to be extraarticular. They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT: ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy. He may be weightbearing as tolerated on his right side. I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion. I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias. He said he has had the left thigh for a number of years and has been followed by a neurologist for this. He states that he has had some right-sided paresthesias now for a number of weeks. He claims he has no other symptoms of any worsening stenosis. I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.soap / chart / progress notes, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal
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{
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"dataset_name": "medical-transcription-40",
"id": 1723
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PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE: ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA: ,Topical.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,The patient was identified. The operative eye was treated with tetracaine 1% topically in the preoperative holding area. The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye. The lashes were tapped using Steri-Strips to prevent blinking. A lid speculum was placed to prevent lid closure. Anesthesia was verified. Then, a 3.5-mm groove was created with a diamond blade temporarily. This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat. A paracentesis was made. A round capsulorrhexis was performed. The anterior capsular flap was removed. Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. The irrigating-aspirating machine was used to clear residual cortex. The Provisc was instilled. An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified. The viscoelastic was removed. Intraocular lens remained well centered. The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. The anterior chamber remained deep, and there was no wound leak. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment. A tight patch and Fox shield were placed. The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.ophthalmology, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, intraocular
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{
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"dataset_name": "medical-transcription-40",
"id": 1724
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SUBJECTIVE:, This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back home each day which takes 20 minutes each way. She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:, Weight is 238.3 pounds. Weight from last week’s visit was 238.9 pounds. Prepregnancy weight is reported at 235 pounds. Height is 62-3/4 inches. Prepregnancy BMI is approximately 42-1/2. Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time. Blood sugar records for the last week reveal the following: Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116. Overall average is 140. A diet history was obtained. Expected date of confinement is May 1, 2005. Instructed the patient on dietary guidelines for gestational diabetes. A 2300 meal plan was provided and reviewed. The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:, Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day. Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day. Her diet history reveals that she is eating three meals a day and three snacks. The snacks were just added last week following presence of ketones in her urine. We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most. We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget. We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy. We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars. While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day. Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis. At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:, Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate. Breakfast: Three carbohydrate servings. Morning snack: One carbohydrate serving. Lunch: Four carbohydrate servings. Afternoon snack: One carbohydrate serving. Supper: Four carbohydrate servings. Bedtime snack: One carbohydrate serving. Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack. Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy. Recommend patient include a fruit or a vegetable with most of her meals. Also recommend including solid protein with each meal as well as with the bedtime snack. Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment: Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units. Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial. Provided my name and number should there be additional dietary questions.consult - history and phy., diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks
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{
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"dataset_name": "medical-transcription-40",
"id": 1725
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XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma. I examined Mrs. ABC initially on MM/DD/YYYY. At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache. She reports a family history of glaucoma in her mother, but is unsure of the specific kind. Her past ocular history has been fairly unremarkable. As you know, she has a history of non-insulin dependent diabetes. She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me. She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses. Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m. Pupillary reactions, confrontational visual fields, and ocular motility were normal. The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure. I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent. I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes. Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs. Her intraocular pressures have remained stable. I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care. If I can provide any additional information or be of further service, do let me know.,Sincerely,,letters, intraocular pressures, narrow angles, visual fields, angles, ophthalmology, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye,
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{
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"dataset_name": "medical-transcription-40",
"id": 1726
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PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,PROCEDURE PERFORMED:,1. Laparotomy.,2. Myomectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS: ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium. Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position. After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife. This was carried through the underlying layer of fascia with a second knife. The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly. It was then dissected in the middle with the Mayo scissors. The inferior aspect of this incision was addressed in a similar manner. The rectus muscles were separated in the midline bluntly. The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly. Next, the uterus was grasped bluntly and removed from the abdomen. The fundal fibroid was identified. It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels. 15 cc was injected. Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was also grasped with Lahey clamp to prevent traction. Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse. The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed. At this point, several smaller fibroids were noticed along the endometrial surface of the uterus. Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size. These were also handed to the scrub tech. Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be completely hemostatic after closure. Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline. The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed. Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline. Then the fascia was closed with #0 Vicryl in a running fashion. Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion. The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately. After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.surgery, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly,
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"id": 1727
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SUBJECTIVE COMPLAINTS: ,Constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. He also has pain and tightness in his low back increased on the left. His pain level is 7/10. He also states that since the accident, he has experienced tension headaches that began in the suboccipital region referring to the top of his head. He has also experienced anxiety and nervousness.,PHYSICAL EXAMINATION: ,Height is 5'10". Weight is 270 pounds.,Visual Evaluation: The patient has anterior head carriage with rounded shoulders. He does not seem to be in any extreme distress. He has slight antalgic head position to the right.,Dynamometer Testing (grip strength) in pounds: The patient is right hand dominant. Right hand 110, 105, and 98. Left hand 80, 70, and 85.,Neurological: Sensation was normal in the upper and lower extremities. Motor strength +5/5 bilaterally in the upper extremities. Reflexes: Upper extremities +2/2 bilaterally, lower extremities patellar +0/2 bilaterally, and S1 +2/2 bilaterally.,Cervical spine range of motion:,Flexion 50/50 with moderate discomfort on the left.,Extension 50/60 with moderate discomfort on the left.,Right lateral bending 40/45 with moderate discomfort on the left.,Left lateral bending 40/45 with moderate discomfort on the right.,Right rotation 70/80 with moderate pain in the left.,Left rotation 70/80 with moderate pain in the left.,Lumbosacral range of motion:,Flexion 60/60.,Extension 25/25.,Right lateral bending 25/25.,Left lateral bending 25/25 with pain in the left.,Right rotation 30/30 with moderate discomfort in the right.,Left rotation 30/30.,Orthopedic Tests: Axial compression negative with moderate pain bilaterally. Shoulder distraction negative with moderate pain bilaterally. Maigne's test negative bilaterally. Valsalva normal and swallow test normal. Heel walk normal. Toe walk normal. Sitting root normal. SLR normal. Patrick-Faber's normal. Iliac compression caused moderate pain in the left.,RADIOLOGY FINDINGS:, X-rays of the cervical and lumbar will be taken today.,DIAGNOSES:,1. Cervical spine sprain/strain.,2. Lumbar spine sprain/strain.,3. Tension headaches.,CAUSATION: ,The patient's symptoms appeared to have come on as a result of the motor vehicle accident consistent with the one described in this report. His history, subjective, and objective findings show evidence from a medical viewpoint that his condition is due to the current injury only and no contributing factors are present from preexisting conditions. The patient's condition is a result of a bony/soft tissue injury that has resulted in an undetermined impairment at this time.,PROGNOSIS: ,The likelihood of nearly complete symptomatic relief within 90 days is excellent. The patient should reach maximum medical improvement in three or four months.,TREATMENT/PLAN: ,After completing an initial examination evaluation, I have selected the plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. Treatment will consist of chiropractic manipulation, chiropractic physical therapy, and observation, decreasing in frequency as the patient's condition allows. I feel it is too early to determine whether this patient will have any residuals or permanent disability.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1728
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CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid
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{
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"dataset_name": "medical-transcription-40",
"id": 1729
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REASON FOR VISIT: ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room. Today, he admits that his pain is much better. Currently, since that time he has been in the splint with minimal pain. He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY: ,The patient is a nonsmoker and does not use illegal drugs. Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand. He has a normal cascade. He has 70 degrees of MCP flexion and full IP flexion and extension. He has 3 to 5 strength in his grip and intrinsics. He has intact sensation to light touch in the radial, ulnar, and median nerve distribution. Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand. They show possible small fractures of the base of the fourth and third metacarpals. Joint appears to be located. A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals. His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus. I would like him to wear this for 2 weeks and then follow up with us. At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist. We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.consult - history and phy., hand pain, pain, hand, metacarpals
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{
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"dataset_name": "medical-transcription-40",
"id": 1730
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PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition.surgery, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1731
}
|
HISTORY OF PRESENT ILLNESS:, Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum." Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed. He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife. ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp and vital signs are all within normal limits.,GENERAL: The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES: Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate. It does not protrude beyond the end of the nail plate. There is no active bleeding. There is no edema or erythema of the digit tip. Flexion and extension of the DIP joint is intact. The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off. In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain. Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip. I was able to grasp the splinter and remove this. No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid. If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.consult - history and phy., horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1732
}
|
LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.,CONCLUSION: ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1. Normal stress/rest cardiac perfusion with no indication of ischemia.,2. Normal LV function and low likelihood of significant epicardial coronary narrowing.,cardiovascular / pulmonary, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1733
}
|
NERVE CONDUCTION TESTING AND EMG EVALUATION,1. Right median sensory response 3.0, amplitude 2.5, distance 100.,2. Right ulnar sensory response 2.1, amplitude 1, distance 90.,3. Left median sensory response 3.0, amplitude 1.2, distance 100.,4. Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5. Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6. Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1. ,RIGHT BICEPS:, Fibrillations 0, fasciculations occasional, positive waves 0. Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2. ,RIGHT TRICEPS:, Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+. Motor units, increased needle insertional activity and decreased number of motor units firing.,3. ,EXTENSOR DIGITORUM:, Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4. ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+. Motor units, decreased number of motor units firing.,5. ,RIGHT ABDUCTOR POLLICIS BREVIS:, Fibrillations 1+, fasciculations 1+, positive waves 0. Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:, Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+. Motor units, decreased number of motor units firing.,7. ,LEFT FIRST DORSAL INTEROSSEOUS:, Fibrillations 1+, fasciculations 1+, positive waves occasional. Motor units, decreased number of motor units firing.,8. ,LEFT EXTENSOR DIGITORUM:, Fibrillations 1+, fasciculations 1+. Motor units, decreased number of motor units firing.,9. ,RIGHT VASTUS MEDIALIS:, Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+. Motor units, decreased number of motor units firing.,10. ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+. Motor units, increased proportion of polyphasic units and decreased number of motor units firing. There is again increased needle insertional activity.,11. ,RIGHT GASTROCNEMIUS:, Fibrillations 1+, fasciculations 1+, positive waves 1+. Motor units, marked decreased number of motor units firing.,12. ,LEFT GASTROCNEMIUS:, Fibrillations 1+, fasciculations 1+, positive waves 2+. Motor units, marked decreased number of motor units firing.,13. ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+. Motor units, decreased number of motor units firing.,IMPRESSION: nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1734
}
|
TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI demonstrated an increased growth with hemorrhage. This was then discontinued. Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion. All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL: ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine. The fluoroscope was then positioned. The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus. Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed. It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent. Once this was ensured and completed and hemostasis obtained, the wound was irrigated. There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate. The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure. All sponge and needle counts were correct. The patient was extubated and transported to the recovery room in stable condition. Blood loss was minimal.surgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1735
}
|
PREOPERATIVE DIAGNOSIS:, Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:, Bilateral ear laceration deformities.,PROCEDURE:,1. Repair of left ear laceration deformity Y-V plasty 2 cm.,2. Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped. The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared. The marsupialized epithelialized tracts were pared to raw tissue. They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge. The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching. Bacitracin, Band-Aid was placed. Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges. This was not taken through the edge of the lobe to decrease the risk of notch deformity. The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge. The 5-0 chromic sutures were used in interrupted fashion for this. The patient tolerated the procedure well. Band-Aid and bacitracin were placed. She left the operating room in stable condition.ent - otolaryngology, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1736
}
|
CHIEF COMPLAINT: , Chronic otitis media, adenoid hypertrophy.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions. He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy. He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes.,ALLERGIES: ,None.,MEDICATIONS:, Antibiotics p.r.n.,FAMILY HISTORY: , Diabetes, heart disease, hearing loss, allergy and cancer.,MEDICAL HISTORY: , Unremarkable.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Some minor second-hand tobacco exposure. There are no pets in the home.,PHYSICAL EXAMINATION:, Ears are well retracted, immobile. Tympanic membranes with effusions present bilaterally. No severe congestions, thick mucoid secretions, no airflow. Oral cavity: Oropharynx 2 to 3+ tonsils. No exudates. Floor of mouth and tongue are normal. Larynx and pharynx not examined. Neck: No nodes, masses or thyromegaly. Lungs: Reveal rare rhonchi, otherwise, clear. Cardiac exam: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender. Positive bowel sounds. Neurologic exam: Nonfocal.,IMPRESSION: ,Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.,PLAN: , The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.consult - history and phy., chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy, pe tubes, otitis media with effusion, adenoidectomy and bilateral myringotomy, eustachian tube dysfunction, insertion of pe, chronic otitis media, bilateral myringotomy, otitis media, adenoidectomy, myringotomy, adenoid, hypertrophy, otitis, media,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1737
}
|
DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT: ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was "slammed from behind" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be "okay to walk." He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that "these things can take a long time." He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS: ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that "I can power through it." "I have learned how to manage the pain, using exercise, stretching, and diversion techniques." It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW: ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as "unknown." The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as "no acute bony process." Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be T7 and T8 on the lateral view." Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1738
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PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.,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 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,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. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. 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 without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,Minimal.,TOTAL TOURNIQUET TIME: ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed. A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws. There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed. There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS: ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall. The patient noted while walking with a walker, apparently tripped and fell. The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room. At that time, a closed reduction was performed and she was placed in a Robert-Jones splint. After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE: ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained. The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia. The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position. At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation. All bony prominences were well padded at this time. A nonsterile tourniquet was placed on the right upper thigh of the patient. This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes. Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle. A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures. Once the bone was reached, the fractured site was identified. The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site. The wound was copiously irrigated and dried. Next, the fracture was then reduced in anatomic position. There was noted to be quite a bit of comminution as well as soft overall status of the bone. It was held in place with reduction forceps. A six hole one-third tubular Synthes plate was then selected for instrumentation. It was contoured using ________ and placed on the lateral aspect of the distal fibula. Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each. The most proximal was a 12 mm and the next two were 16 mm in length. Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole. The most distal with a 20 mm and two most proximal were 18 mm in length. Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position. There was no lateralization of the joints. Attention was then directed towards the medial aspect of the ankle. Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus. Again, the dissection was carefully taken down the level of the fracture site. The retractors were then placed to protect all neurovascular structures. Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum. The fracture site was then displaced and the ankle joint was visualized including the dome of the talus. There appeared to be some minor degenerative changes of the talus, but no loose bodies. Next, the wound was copiously irrigated and suctioned dry. The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire. Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length. These appeared to hold the fracture site securely in an anatomic position. Again, Xi-scan was brought in to confirm placement of the screws. They were in good overall position and there was no lateralization of the joint. At this time, each wound was copiously irrigated and suctioned dry. The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin. A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril. A Robert-Jones style splint was then placed on the right lower extremity. This was covered by a 4-inch Depuy dressing. At this time, the Department of Anesthesia reversed the sedation. The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit. The patient tolerated the procedure well. There were no complications.orthopedic, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
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HISTORY:, The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss. The patient reports that she has been having history of recurrent sinus infection, averages about three times per year. During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well. The patient does note that she has been having hearing loss. This is particular prominent in the right ear now for the past three to four years. She does note popping after blowing the nose. Occasionally, the hearing will improve and then it plugs back up again. She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her. She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement. She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage. She feels that she is having a hard time swallowing at times as well. She has complained of a lump sensation in the throat that tends to come and go. She denies any cough, no hemoptysis, no weight change. No night sweats, fever or chills has been noted. She is having at this time no complaints of tinnitus or vertigo. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: ,ALLERGY/IMMUNOLOGIC: History of seasonal allergies. She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR: Pertinent for hypercholesterolemia.,PULMONARY: She has a history of cough, wheezing.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: She has had a history of TIAs in the past.,VISUAL: She does have history of vision change, wears glasses.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: History of joint pain and bursitis.,CONSTITUTIONAL: She has a history of chronic fatigue.,ENT: She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC: History of anxiety, depression.,HEMATOLOGIC: Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984. She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension. Brother, colon CA. Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily. She takes vitamins one a day. She is on Zocor, Desyrel, Flonase, and Xanax. She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling. She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single. She is unemployed at this time. She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL: The patient is an alert, cooperative, well-developed 51-year-old female. She has a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Right ear, the external ear is normal. The ear canal is clean and dry. The drum is intact. She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss. Left ear, the external ear is normal. The ear canal is clean and dry. The drum is intact and mobile with grossly normal hearing. The audiogram does reveal normal hearing in the left ear. She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally. Tympanograms, there was no adequate seal obtained on the right side. She has a normal type A tympanogram, left side.,NASAL: Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms. Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted. The nasopharynx does reveal moderate adenoid pad within this midline. It is nonulcerated. The larynx revealed both cords to be normal. She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION: ,1. Persistent dysphagia. I think secondary most likely to the persistent postnasal drainage.,2. Deviated nasal septum.,3. Inferior turbinate hypertrophy.,4. Chronic rhinitis.,5. Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1741
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PREOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 35-1/7.,2. Rh isoimmunization.,3. Suspected fetal anemia.,4. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 35-1/7.,2. Rh isoimmunization.,3. Suspected fetal anemia.,4. Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:, Spinal anesthesia.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:, Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid. Apgars 7 and 8 at 1 and 5 minutes respectively. Weight pending at this time. His name is Kasson as well as umbilical cord and placenta stained yellow. Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:, After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties. The patient was placed in supine position with leftward tilt. Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion. At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery. The fascia was nicked sharply in the midline. The fascial incision was extended laterally with Mayo scissors. The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors. Attention was then turned to the superior aspect of the fascial incision. Fascia was grasped, elevated, and rectus muscles dissected off sharply. The rectus muscles were separated in the midline bluntly. The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder. Bladder blade was inserted. Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors. Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel. Uterine incision was extended laterally and manually. Membranes were ruptured and bright yellow clear amniotic fluid was noted. Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex. Nares and mouth were suctioned with bulb suction. Remainder of the infant was delivered atraumatically. The infant was very pale upon delivery. Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team. An 8 cm segment of the tube was doubly clamped and transected. Cord gases were obtained. Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements. At this time, it was noted that the cord was significantly yellow stained as well as the placenta. At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage. Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion. Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis. At this time, the uterine incision was hemostatic. The bladder was examined and found to be well below the level of the incision repair. Tubes and ovaries were examined and found to be normal. The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp. Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed. Hemostasis was noted. Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp. Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted. Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen. Gutters were cleared off all clots and debris. Lower uterine segments were again re-inspected and found to be hemostatic. Sites of tubal sterilization were also visualized and were hemostatic. At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture. Copious irrigation was used. Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline. At this time, the fascia was closed using 0 Vicryl in a running fashion. Manual palpation confirms thorough and adequate closure of the fascial layer. Copious irrigation was again used. Hemostasis noted, and skin was closed with staples. The patient tolerated the procedure well. Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition. Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia. The patient will be followed for her severe right upper quadrant pain post delivery. If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus. This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.surgery, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord,
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{
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"dataset_name": "medical-transcription-40",
"id": 1742
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HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:, Penicillin.,SOCIAL HISTORY:, He is not a smoker. He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT: Examination unremarkable.,Breasts: Examination deferred.,Chest: Clear to auscultation.,Cardiac: Regular rate and rhythm.,Abdomen: Soft and nontender. He has no hernias.,Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities: Examination unremarkable.,Neurologic: Examination nonfocal.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Erectile dysfunction.,PLAN: ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.consult - history and phy., gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1743
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EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.radiology, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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PREOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL: ,The patient was electively taken to the operating room after obtaining an informed consent. A time-out process was followed. Antibiotics were given. Then, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated. The right subclavian vein was percutaneously cannulated without any difficulty. Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.,A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl. Then, the fascia was closed using subcuticular suture of Monocryl. The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed. A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.,The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.surgery, metastatic carcinoma of the bladder, percutaneously, subclavian vein, port insertion, metastatic carcinoma, bowel obstruction, catheter
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{
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"dataset_name": "medical-transcription-40",
"id": 1745
}
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VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. Hemostasis was maintained with wet-field cautery. Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant. A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the preplaced sutures. An 8-0 nylon suture was then preplaced for a later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on. Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.ophthalmology, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: 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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1746
}
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PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper extremity. She has difficulty with pushing and pulling and lifting with her right arm. She describes an intermittent tingling sensation in the volar aspect of her right hand. She states she has diminished grip strength in her right hand because of wrist pain complaints. She states that the Wellbutrin samples I had given her previously for depression seem to be helping. Her affect appears appropriate. She reports no suicidal ideation. She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints. She also takes Imitrex occasionally for headache complaints related to her neck pain. She also takes Flexeril occasionally for back spasms and Darvocet for pain. She is asking for a refill on some of her medications today. She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile. Blood pressure is 106/68, pulse of 64, respirations of 20. Her physical exam is unchanged from 03/21/05. Her orthopedic exam reveals full range of motion of the cervical spine. Cervical compression test is negative. Valsalva's maneuver is negative. Hoffmann's sign is negative. DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally. Her sensation is grossly intact to the upper extremity dermatomes. Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists. Passive range of motion of the right wrist is painful for her. Passive range of motion of the left wrist is non painful. Active range of motion of both wrists and hands are full. She is right hand dominant. Circumferential measurements were taken in her upper extremities. She is 11" in the right biceps, 10 1/2" in the left biceps. She is 9 3/4" in both right and left forearms. Circumferential measurements were also taken of the lower extremities. She is 21" at both the right and left thighs, 15" in both the right and left calves. Jamar dynamometry was assessed on three tries in this right-hand-dominant individual. She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand. , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12" from touching the floor. Lumbar extension is to 30 degrees. The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh. The left SLR is to 90 degrees without back pain. DTRs are +1 at the knees and ankles. Toes are downgoing to plantar reflexes bilaterally. Sensation is grossly intact in the lower extremity dermatomes. Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1) Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2) Cervical sprain/strain with myofascial dysfunction. (3) Thoracic sprain/strain with myofascial dysfunction. (4) Probable chronic tendonitis of the right wrist. She has negative nerve conduction studies of the right upper extremity. (5) Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory. I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:, I told the patient to continue her medication course per above. It seems to be helping with some of her pain complaints. I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms. I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04. , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager. She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground. She had onset of headaches and neck pain, and pain complaints about her right upper extremity. She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain. , ,FACTORS FOR DISABILITY:,OBJECTIVE: ,1. She exhibits decreased range of motion in the lumbar trunk.,2. She has an abnormal MRI revealing a disc herniation at L5-S1.,3. She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1. Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2. With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3. Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4. Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds. She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain. She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates. She also relates headaches, which she did not have prior to her industrial injury. , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient. It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort. The patient should probably no lift more than 15 to 20 pounds maximally. She should probably not repetitively bend or stoop. She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand. She should probably not lift more than 10 pounds repetitively with the right upper extremity. I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity. , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04. There does not appear to be any apportionable issues here.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1747
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PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. The benefits are ease of care and cleanliness and fewer urinary tract infections. The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE: ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner. Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed. Dorsal hemostasis was established and a dorsal slit was made. The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed. The infant was fitted with a XX-cm Plastibell. The foreskin was retracted around the Plastibell and circumferential hemostasis was established. The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss. Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.urology, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1748
}
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REASON FOR EVALUATION:,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1749
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SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain. She has a history of prior laminectomy for spinal stenosis. She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic. Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005. She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip. An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study. Dr. XYZ had performed right intraarticular hip injection on 04/07/2005. She was last seen on 04/15/2005. At that time, she had the hip injection that helped her briefly with her pain. She is not sure whether or not she wants to proceed with hip replacement. We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today. She continues to complain of significant pain in her right hip, especially with weightbearing or with movement. She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her. She is taking Ultracet or other the generic it sounds like, up to four times daily. She states she can take this much more frequently as she still has significant pain symptoms. She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:, Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General: Reveals a pleasant Caucasian female.,Vital Signs: Height is 5 feet 4 inches. Weight is 149 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Musculoskeletal: Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left. Straight leg raises are negative bilaterally. Posterior tibials are palpable bilaterally.,Skin and Lymphatics: Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers. No significant lymphadenopathy noted.,Spine: Examination shows lumbar scoliosis with surgical scar with no major tenderness. Spinal movements are limited but functional.,Neurological: She is alert and oriented with appropriate mood and affect. She has normal tone and coordination. Reflexes are 2+ and symmetrical. Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:, Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1. Degenerative disk disease of the right hip, symptomatic.,2. Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3. Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4. Facet and sacroiliac joint syndrome on the right, stable.,5. Post left hip arthroplasty.,6. Chronic pain syndrome.,RECOMMENDATIONS:, The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement. In the interim, her Ultracet is not quite taking care of her pain. I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day. I have written a prescription for this for 120 tablets and two refills. The patient will call for the refills when she needs them. I will plan further follow up in six months, sooner if needed. She voiced understanding and is in agreement with this plan. Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.orthopedic, scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1750
}
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PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1. Open reduction and internal screw fixation right fifth metatarsal.,2. Application of short leg splint.,ANESTHESIA:, TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal. The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot. She continued to walk on the foot and found nothing was wrong despite the pain. She was recently seen by Dr. X and was referred to Dr. Y for surgery. The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y. The consent is available on the chart for review. The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL: ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and a sterile stocking was reflected. Attention was directed to the right fifth metatarsal base. The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal. An avulsion fracture of the right fifth metatarsal base was visualized. The fracture was linear in nature from distal lateral to proximal medial. There appeared to be a pseudoarthrosis on the lateral view. A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve. A linear incision was created with a #10 blade. A #15 blade was used to deepen the incision through the subcutaneous tissue. All small veins traversing the subcutaneous tissue were ligated with electrocautery. Next, using combination of sharp and blunt dissection, the deep fascia was reached. Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade. Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone. The fracture site was not clearly visualized due to bony callus. A #25 gauge needle was introduced into the fracture site under fluoroscopy. The fracture site was easily found. An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone. Next, a small ball burr was used to resect the remaining hypertrophic bone. Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone. Next, a bone clamp was applied and the fracture was reduced. Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally. A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly. All this was done under fluoroscopy. Next, the wound was flushed with copious amounts of sterile saline. The fracture site was found to have rigid compression. The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed. Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion. A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique. Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique. A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance. A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot. Next, copious amounts of Webril were applied to pad all bony prominences. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. Next, 4-inch, pre-moulded, well-padded posterior splint was applied. The capillary refill time of the digits was less than three seconds. The patient tolerated the above anesthesia and procedure without complications. After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone. She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches. She will rest, ice, and elevate her right leg. She is to follow up in the clinic on 08/26/03 at 10:30 a.m.. She was given emergency contact numbers and will call or return if problems arise earlier.orthopedic, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif
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{
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"dataset_name": "medical-transcription-40",
"id": 1751
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PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium. There was spontaneous echocardiogram contrast noticed. The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed. The pads applied in the anterior and posterior approach. With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm. The patient had some occasional PACs noticed with occasional sinus tachycardia. The patient had no immediate post-procedure complications. The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION: ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.surgery, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils. The patient has been having difficult time with having two to three bouts of tonsillitis this year. She does average about four bouts of tonsillitis per year for the past several years. She notes that throat pain and fever with the actual infections. She is having no difficulty with swallowing. She does have loud snoring, though there have been no witnessed observed sleep apnea episodes. She is a mouth breather at nighttime, however. The patient does feel that she has a cold at today's visit. She has had tonsil problems again for many years. She does note a history of intermittent hoarseness as well. This is particularly prominent with the current cold that she has had. She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home. For the two tonsillitis, she is on antibiotics again on an average about four times per year. They do seem to help with the infections, but they tend to continue to recur. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC: Negative.,CARDIOVASCULAR: Negative.,PULMONARY: Negative.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: Negative.,VISUAL: Negative.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: Negative.,CONSTITUTIONAL: Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:, No family history of bleeding disorder. She does have a sister with a current ear infection. There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single. She is a student. Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL: The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: The external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. Hearing is grossly normal. Tuning fork examination with normal speech reception thresholds noted.,NASAL: She has clear drainage, large inferior turbinates, no erythema.,ORAL: Her tongue, lip, floor of mouth are noted to be normal. Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic. Mirror examination of the larynx reveals some mild edema of the larynx at this time. The nasopharynx could not be visualized on mirror exam today.,NECK: Obese, supple. Trachea is midline. Thyroid is nonpalpable.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,IMPRESSION: , ,1. Chronic adenotonsillitis with adenotonsillar hypertrophy.,2. Upper respiratory tract infection with mild acute laryngitis.,3. Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy. All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family. This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc. The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks. We will make further recommendations afterwards.nan
|
{
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"dataset_name": "medical-transcription-40",
"id": 1753
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TITLE OF OPERATION:, Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07. Subsequently, biopsy confirmed tumor persistence in the right glottic region. Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail. Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level. The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives. He was accompanied by his wife and daughter. Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table. After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm. A #6 endotracheal tube was placed initially. Direct laryngoscopy was performed with a Lindholm laryngoscope. A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis. Subsequently, a decision was then made to go ahead and perform the surgical intervention. A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected. A shoulder roll was applied after the patient was prepped and draped in a sterile fashion. Subsequently, a hemi-apron incision was performed. Subplatysmal flaps were raised at the hyoid bone into the clavicle. Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed. Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle. Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle. The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified. Level 2A contents were then dissected off the floor of the neck including levels 3 and 4. Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4. The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve. Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed. Subsequently, the strap muscles were separated in the midline. The trachea was identified in the midline. The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage. Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively. The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular. Attention was then turned to performing a cricothyrotomy. Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision. A #7 anode tube was then placed in this area and secured. Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis. Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine. It was evident that this tumor had extended more than 1 cm into the subglottic region. Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded. Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy. Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin. A W-plasty was also performed to allow for enlargement of the stoma. Attention was then turned to identifying the common parting wall of the trachea and the esophagus. Attention was then turned to resecting the hyoid bone. The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism. The wound was copiously irrigated. Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect. Once this was performed, a running 3-0 canal stitch was used to close the pharynx. Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied. Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon. The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin. The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.endocrinology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1754
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CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:, No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ): There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:, The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1755
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FINAL DIAGNOSIS/REASON FOR ADMISSION:,1. Acute right lobar pneumonia.,2. Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3. Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4. Elevated liver function tests, etiology undetermined.,5. The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6. Anemia secondary to current illness and possible iron deficiency.,7. Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009. Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic. Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS: ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough. Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate. She was started on antibiotics. Infectious Disease was consulted. She was initially begun on vancomycin. Blood, sputum, and urine cultures were obtained; the results of which were negative for infection. She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis. During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning. Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour. She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment. Due to some elevated liver function tests, she was seen in consultation by Dr. X. An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder. A HIDA scan was performed and revealed no evidence of gallbladder dysfunction. Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value. She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics. Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%. She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay. Blood cultures were negative at 5 days. Sputum culture was negative. Urine culture was negative and thoracentesis culture negative at 24 hours. The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained. Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8. Her PT and PTT were normal. Occult blood studies were negative for occult blood. Hepatitis B antigen was negative. Hepatitis A antibody IgM was negative. Hepatitis B core IgM negative, and hepatitis C core antibody was negative. At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved. She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.general medicine, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1756
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HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1757
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PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops. A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg. The eye was prepped with a Betadine solution and draped in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic. A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition.surgery, phacoemulsification, hydrodissection, peribulbar block, irrigation and aspiration, honan balloon, anterior chamber, anterior capsular, aspiration unit, capsular bag, cataract extraction, intraocular lens, cataract, extraction, peribulbar, lidocaine, viscoelastic, chamber, epinephrine, anterior, capsular, lens, intraocular, eye,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1758
}
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PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty. The right arm, axilla, and chest wall were prepped and draped in sterile fashion. Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent. The draining veins are the deep brachial veins. The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture. A nice length of vein was obtained to the distal one third of the arm. This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein. A transverse skin incision was made over the superior aspect of the old fistula vein. This vein was carefully dissected out and encircled with vascular tapes. The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula. The patient was sensible, was then systemically heparinized. The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter. The brachial vein end was spatulated. Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion. After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled. The anastomosis was completed. A nice thrill could be palpated over the outflow brachial vein. Hemostasis was noted. A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture. The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin. Sterile dressings were applied. The patient was then x-ray'd and taken to Recovery in satisfactory condition. Estimated blood loss 50 mL, drains 8 mm Blake. Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.surgery, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1759
}
|
ADMISSION DIAGNOSIS:, Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:, Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:, Stable.,PROCEDURES PERFORMED:, Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE: ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. The patient recovered well after this. Working with PT, she was able to ambulate with minimal assistance. Nerve block was removed by anesthesia. The patient did well on oral pain medications. The patient was discharged home. She is actually going to home with her son who will be able to assist her and look after her for anything she might need. The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks.orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1760
}
|
SUBJECTIVE:, The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS: Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL: The patient looks tired.,HEENT: Oral mucosa is dry.,CHEST: Clear to auscultation. He states that he has a mild cough, not productive.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Soft and nontender. Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES: There is no swelling.,NEURO: The patient is alert and oriented x 3. Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000. Glucose is in the low 100s. Comprehensive metabolic panel is unremarkable. UA is negative for infection.,ASSESSMENT AND PLAN:,1. Fever of undetermined origin, probably viral since white count is normal. Would continue current antibiotics empirically.,2. Dehydration. Hydrate the patient.,3. Prostatic hypertrophy. Urologist, Dr. X.,4. DVT prophylaxis with subcutaneous heparin.soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1761
}
|
INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED: ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:, The tip of the endoscope was introduced into the rectum. Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions. The rest of the colon through to the cecum was well visualized. The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified. There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation. Adverse reactions none.,IMPRESSION:, Normal colonic mucosa through to the cecum. There was no evidence of tumor or polyp.gastroenterology, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1762
}
|
EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.orthopedic, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1763
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|
DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. Cord clamped and cut and infant handed to the awaiting nurse in attendance. Cord blood sent for analysis, intact. Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours. A 15 units of Pitocin was started after delivery of the placenta. Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion. Estimated blood loss was approximately 400 mL. The patient was taken to the recovery room in stable condition. Infant was taken to Newborn Nursery in stable condition. The patient tolerated the procedure well. The only intrapartum event that occurred was thick meconium. Otherwise, there were no other complications. The patient tolerated the procedure well.obstetrics / gynecology, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: 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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1764
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DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1765
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PREOPERATIVE DIAGNOSIS:, Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Right inguinal hernia.,PROCEDURE:, Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia. The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion. An incision was made in the right inguinal skin crease. The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring. The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed. The distal remnant was taken to its end and excised. The testicle and cord structures were placed back in their native positions. The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips. The patient was extubated in the operating room and taken back to the recovery room. The patient tolerated the procedure well.surgery, inguinal skin crease, inguinal hernia repair, external oblique, hernia repair, inguinal hernia, inguinal, hernia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1766
}
|
1. Pelvic tumor.,2. Cystocele.,3. Rectocele.,POSTOPERATIVE DIAGNOSES:,1. Degenerated joint.,2. Uterine fibroid.,3. Cystocele.,4. Rectocele.,PROCEDURE PERFORMED: ,1. Total abdominal hysterectomy.,2. Bilateral salpingooophorectomy.,3. Repair of bladder laceration.,4. Appendectomy.,5. Marshall-Marchetti-Krantz cystourethropexy.,6. Posterior colpoperineoplasty.,GROSS FINDINGS: The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. Curettings were negative for malignancy. The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy. The ovaries appeared to be within normal limits. There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized. No other pathology noted from the abdominal cavity or adhesions. The upper right quadrant of the abdomen compatible with a previous gallbladder surgery. The appendix is in its normal anatomic position. The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident. There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE: The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia. A midline incision was made around the umbilicus down to the lower abdomen. With a #10 Bard Parker blade knife, the incision was carried down through the fascia. The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors. A Balfour retractor was placed into the wound. This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care. The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture. The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus. The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament. An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered. After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus. The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture. After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak. Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply. The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture. The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors. A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors. The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect. The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture. The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision. The pelvis was irrigated with approximately 500 cc of water. The appendix was grasped with Babcock forceps. The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors. The curved hemostats were placed with #00 Vicryl suture. The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl. No bleeding was noted. Sponge, instrument, and needle counts were found to be correct. All packs and retractors were removed. The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture. Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples. Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands. An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors. The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally. In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture. Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture. The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture. The skin was closed with a running #000 plain gut subcuticular stitch. The vaginal vault was packed with a Betadine-soaked Kling gauze sponge. Sterile dressing was applied. The patient was sent to recovery room in stable condition.urology, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine, mucosa, scissors, ligament, bladder
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1767
}
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CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity. 2) VBG, 1990. 3) A-Fib. 4) HTN. 5) Hypothyroidism. 6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since.neurology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1768
}
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CHIEF COMPLAINT:, Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain. He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain. He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS: ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker. Admits to heroin use, alcohol abuse as well. Also admits today using cocaine.,FAMILY HISTORY:, Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically. Apparently, he just recently got out of prison. He has previously also been on Klonopin and lithium. He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient is afebrile. He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard. His respiratory rate is normal at 18. GENERAL: The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation. HEENT: Unremarkable. Pupils are actually moderately dilated about 4 to 5 mm, but reactive. Extraoculars are intact. His oropharynx is clear. NECK: Supple. His trachea is midline. LUNGS: Clear. He has good breath sounds and no wheezing. No rales or rhonchi. Good air movement and no cough. CARDIAC: Without murmur. ABDOMEN: Soft and nontender. He has multiple track marks, multiple tattoos, but no abscesses. NEUROLOGIC: Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN: ,At this time, I think the patient can be followed up at XYZ. I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy. I do not think he needs any further workup at this time. He is discharged otherwise in stable condition.general medicine, phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1769
}
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PREOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,PROCEDURE,1. Removal of cystic lesion, left posterior mandible.,2. Removal of teeth numbers 4, 13, 20, and 29.,3. Removal of teeth numbers 1 and 16.,4. Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome. Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position. Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures. The oral cavity was suctioned, was drained of fluid and a throat pack was placed. General anesthesia nursing service was notified and which was removed at the end of the procedure. Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL. A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth. Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt. Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle. Secondly, tooth number 4 was removed. Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side. Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9. This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion. These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure. Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar. The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle. This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin. Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure. Teeth number 20 and 29 where removed and 3-0 chromic suture placed. This concluded the procedure. All cottonoids and other sponges, throat pack were removed. No complications were encountered. The aforementioned cystic lesion was sent with specimen no drains were placed. The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.dentistry, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1770
}
|
PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:, Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. First the trachea and the carina had normal appearance. The scope was passed into the left side and the bronchial system was found to be normal. There were scars and mucoid secretions. Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB. First, the basal lobes were explored and found to be normal. Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,surgery, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1771
}
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HISTORY:, The patient presents today for medical management. The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. She has been off her supplements for four weeks with some improvement. She has loose bowel movements. She complains of no bladder control. She has pain in her hips. The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1. Type II diabetes mellitus.,2. Generalized fatigue and weakness.,3. Hypertension.,4. Peripheral neuropathy with atypical symptoms.,5. Hypothyroidism.,6. Depression.,7. Long-term use of high-risk medications.,8. Postmenopausal age-related symptoms.,9. Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.,PAST SURGICAL HISTORY:, As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy.,SOCIAL HISTORY: ,She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL: Certainly at the present time on general exam no fever, sweats or chills and no significant weight change. She is 189 pounds currently and she was 188 pounds in January.,HEENT: HEENT, there is no marked decrease in visual or auditory function. ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY: Chest, there is no history of palpitations, PND or orthopnea. The chest pains are nonspecific, tenderness to palpation has been reported. There is no wheezing or cough reported.,CARDIOVASCULAR: No PND or orthopnea. Thromboembolic disease history.,GASTROINTESTINAL: Intermittent symptoms of stomach pain, they are nonspecific. No nausea or vomiting noted. Diarrhea is episodic and more related to nerves.,GENITOURINARY: She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL: Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL: No marked paralysis, paresis or paresthesias.,SKIN: No rashes, itching or changes in the nails.,BREASTS: No report of any lumps or masses.,HEMATOLOGY AND IMMUNE: No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT: 189 pounds. BP: 140/80. PULSE: 76. RESPIRATIONS: 20. GENERAL APPEARANCE: Well developed, well nourished. No acute distress.,HEENT: Head is normocephalic. Ears, nose, and throat, normal conjunctivae. Pupils are reactive. Ear canals are patent. TMs are normal. Nose, nares patent. Septum midline. Oral mucosa is normal in appearance. No tonsillar lesions, exudate or asymmetry. Neck, adequate range of motion. No thyromegaly or adenopathy.,CHEST: Symmetric with clear lungs clear to auscultation and percussion.,HEART: Rate and rhythm is regular. S1 and S2 audible. No appreciable murmur or gallop.,ABDOMEN: Soft. No masses, guarding, rigidity, tenderness or flank pain.,GU: No examined.,EXTREMITIES: No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS: Intact. No lesions or rashes.,NEUROLOGIC: Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1772
}
|
PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:, 400 ml.,SPECIMENS REMOVED:, Not applicable.,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 fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1. Type 2 aortic arch.,2. Left subclavian artery was patent.,3 Left vertebral artery was patent.,4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:, Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.radiology, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1773
}
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PREOPERATIVE DIAGNOSIS: , Cervical lymphadenopathy.,POSTOPERATIVE DIAGNOSIS:, Cervical lymphadenopathy.,PROCEDURE: , Excisional biopsy of right cervical lymph node.,ANESTHESIA: , General endotracheal anesthesia.,SPECIMEN: , Right cervical lymph node.,EBL: , 10 cc.,COMPLICATIONS: , None.,FINDINGS:, Enlarged level 2 lymph node was identified and removed and sent for pathologic examination.,FLUIDS: , Please see anesthesia report.,URINE OUTPUT: , None recorded during the case.,INDICATIONS FOR PROCEDURE: , This is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy. She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic. After risks and benefits of surgery were discussed with the patient, an informed consent was obtained. She was scheduled for an excisional biopsy of the right cervical lymph node.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in the supine position. She was anesthetized with general endotracheal anesthesia. The neck was then prepped and draped in the sterile fashion. Again, noted on palpation there was an enlarged level 2 cervical lymph node.,A 3-cm horizontal incision was made over this lymph node. Dissection was carried down until the sternocleidomastoid muscle was identified. The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation. The area was then explored for any other enlarged lymph nodes. None were identified, and hemostasis was achieved with electrocautery. A quarter-inch Penrose drain was placed in the wound.,The wound was then irrigated and closed with 3-0 interrupted Vicryl sutures for a deep closure followed by a running 4-0 Prolene subcuticular suture. Mastisol and Steri-Strip were placed over the incision, and sterile bandage was applied. The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition. She will return to the office tomorrow in followup to have the Penrose drain removed.surgery, lymphadenopathy, excisional biopsy, fna, mastisol, penrose drain, cervical, cervical lymph node, endotracheal anesthesia, lymph node, sternocleidomastoid, cervical lymph, lymph, anesthesia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1774
}
|
PREOPERATIVE DIAGNOSIS:, Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Pelvic endometriosis.,3. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Laparoscopy.,2. Harmonic scalpel ablation of endometriosis.,3. Lysis of adhesions.,4. Cervical dilation.,ANESTHESIA: ,General.,SPECIMEN: ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:, Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. There are adhesions involving the right ovary to the anterior abdominal wall and the bowel. There are also adhesions from the omentum to the anterior abdominal wall near the liver. The uterus and ovaries appear within normal limits other than the adhesions. The left fallopian tube grossly appeared within normal limits. The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized. There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac. There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE: ,The patient was taken in the operating room and generalized anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. After exam under anesthetic, weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen. An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife. The superior aspect of the umbilicus was grasped with a towel clamp. The abdomen was tented up and a Veress needle inserted through this incision. When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle. This was seen to freely drop in the abdomen so it was connected to CO2 gas. Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting. The abdomen was then insufflated to an adequate distention. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. Next, the laparoscope was inserted through this port. The medial port was connected to CO2 gas. Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis. Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed. Next, a grasper was placed through the suprapubic port. This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions. Bowel was carefully examined afterwards and no injuries or bleeding were seen. Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty. There was a small amount of bleeding from the anterior abdominal wall peritoneum. This was ablated with the Harmonic scalpel. The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac. Both of these areas were seen to be hemostatic. Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac. This was sent to pathology. Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed. It was seen to be completely hemostatic. Next, the two size #5 ports were removed under direct visualization. The camera was removed. The abdomen was desufflated. The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.surgery, pelvic pain, endometriosis, pelvic adhesions, laparoscopy, scalpel ablation, lysis of adhesions, cervical dilation, peritoneal biopsy, harmonic scalpel, adhesions, harmonic, scalpel, abdominal, pelvic, abdomen, anterior,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1775
}
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PREOPERATIVE DIAGNOSIS:, Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presented unfortunately because of nonaccidental trauma. The patient suffered neurologic devastation. In order to facilitate enteral feedings, the plan is to place a G-tube as the patient cannot take by mouth. Consent was obtained by court order as the patient is a ward of the state.,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 the usual sterile fashion. An incision was made through the umbilicus. Peritoneal cavity entered bluntly. A 5-mm trocar was introduced. Abdomen was insufflated with a 5-mm scope. No obvious pathology noted. We visualized the stomach. We chose the spot in the left upper quadrant for future G-tube site. I made a small incision on the skin there, put another 5-mm trocar at that site. Using a Babcock, we grasped the stomach along the greater curvature site for further G-tube. I pulled a knuckle of stomach through the incision and secured with 4-0 Vicryl. I then used 3-0 Prolene sutures as tacking sutures on either side of the future G-tube site taking full-thickness abdominal wall through stomach and back out the abdominal wall. I then pulled the knuckle of stomach back up through the incision, made a gastrotomy, and then put a 4-0 pursestring around the gastrotomy site, introduced the 14, 1.2- cm MIC-Key into the stomach. The gastrotomy site insufflated with 5 mL of saline. We then tied down the pursestring. On the laparoscopy, the G-tube looked to be in good position. I insufflated the stomach through the G-tube, which I did and removed air subsequently. I then placed 2 x 2 underneath the G-tube and tied down tacking sutures around the G-tube itself, placed the G-tube to gravity, desufflated the abdomen, closed the umbilical port site fascia with 3-0 Vicryl, closed skin with 5-0 Monocryl, and dressed with bacitracin, 2 x 2, and Steri-Strips. The patient was extubated in the operating room and taken back to recovery room. The patient tolerated the procedure well.surgery, neurologic devastation, g-tube placement, mic-key, laparoscopic g-tube placement, babcock, g-tube site, gastrotomy, mic key, abdominal wall, gastrotomy site, nonaccidental trauma, tube, stomach,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1776
}
|
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:, Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:, General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, 1200 cc.,FLUIDS:, 2700 cc.,URINE:, 400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS: ,Placenta, cord gases and cord blood.,INDICATIONS: ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions. She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm. A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally. There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained. The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery. She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this. After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered. She was then prepped and draped in the normal sterile fashion. Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered. Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife. The fascia was incised in the midline with a second knife. This incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps. It was then dissected in the midline with Mayo scissors. The inferior aspect of this incision was then addressed in a similar manner. The rectus muscles were then separated in the midline with a hemostat. The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly. Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors. This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly. Next, the bladder blade was placed. The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors. This incision was extended laterally in both directions and a bladder flap was created digitally. The bladder blade was then reinserted. Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife. Next, the uterine incision was extended laterally in both directions with the banded scissors. Next, the infant's head and body were delivered without difficulty. There was multiple section on the abdomen. The cord was clamped and cut. Section of cord was collected for gases and the cord blood was collected. Next, the placenta was manually extracted. The uterus was exteriorized and cleared of all clots and debris. The edges of the uterine incision were then identified with Allis _______ clamps. The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis. One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid. After several minutes of observation, the hematoma was seem to be non-expanding. The uterus was replaced in the abdomen. The uterine incision was reexamined and seem to be continuing to be hemostatic. The pelvic gutters were then cleared of all clots and debris. The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion. The peritoneum was then closed with #0 Vicryl in a running fashion. The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch. The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x3. The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1777
}
|
PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs. The patient has now begun to have comorbidities related to the obesity. The patient has attended our bariatric seminar and met with our dietician and psychologist. The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient. Consent was obtained. The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. A Foley catheter was placed for bladder decompression. All pressure points were carefully padded, and sequential compression devices were placed on the legs. The abdomen was prepped and draped in standard, sterile, surgical fashion. Marcaine was injected into the umbilicus.surgery, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1778
}
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REASON FOR CONSULTATION:, Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY: ,Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES: ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS: ,The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1779
}
|
PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with Betadine. The patient was given sedation and monitored. Under fluoroscopy, the right sacral alar notch was identified. After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained. Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected. Coagulation was then carried out at 90oC for 90 seconds. The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint. Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications. The patient was returned to outpatient recovery in stable condition.radiology, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1780
}
|
PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:, Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,SPECIMENS:, Urine sent for culture.,ABNORMAL FINDINGS: ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices. Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS: ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction. He has had a STING procedure performed but continues to have reflux bilaterally. Plan is for another injection.,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, IV antibiotics were given. He was then placed in a lithotomy position with adequate padding of his arms and legs. His urethra was calibrated to 12-French with a bougie a boule. A 9.5-French cystoscope was used and the offset system was then used. His urethra was normal without valves or strictures. His bladder was fairly normal with minimal trabeculations but no cystitis noted. Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone. This was similarly found on the left side where the Deflux was not close to the orifice as well. It was slightly more difficult because of the amount impacted upon our angle for injection. We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect. Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding. Similar procedure was done on the left. This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed. There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection. At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra. The patient tolerated the procedure well and was in stable condition upon transfer to Recovery. A low-dose of IV Toradol was given at the end of the procedure as well.surgery, bilateral vesicoureteral reflux, deflux, sting procedure, hit technique, cystoscopy under anesthesia, hit/sting with deflux, vesicoureteral reflux, ureteral orifices, vesicoureteral, cystoscopy, urethra, hit/sting, ureteral,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1781
}
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DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2. Negative EKG criteria for ischemia.,3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management.cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1782
}
|
FINAL DIAGNOSES:,1. Gastroenteritis.,2. Autism.,DIET ON DISCHARGE:, Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. She developed vomiting 3 days prior to admission, but did not have diarrhea. She voided on the day of admission. When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight. She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA: ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64. Chest x-ray and abdominal films were unremarkable. Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800. Urinalysis was negative for ketones. Specific gravity 1.023, and negative for protein. Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118. Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE: ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated. On the second hospital day, mother was comfortable taking her to home. Mother did not have a good explanation for the weight loss. In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94. Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge. We will follow up in the office and try to further evaluate her for the unexplained weight loss. She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss. The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.discharge summary, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1783
}
|
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.discharge summary, 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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1784
}
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PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.surgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1785
}
|
PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS: ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent. The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. All pressure points were carefully padded. She was given general anesthesia with endotracheal intubation. SCD stockings were placed on both legs. Foley catheter was placed for bladder decompression. The abdomen was then prepped and draped in standard sterile surgical fashion. Marcaine was then injected through umbilicus. A small incision was made. A Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg. A 12-mm VersaStep port was placed through the umbilicus. I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side. I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port. On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port. A few centimeters below and medial to that, I placed a 15-mm port. I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz. I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler. I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device. I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis. I reapproximated the edges of the defect. I lifted it up and stapled across it with another white load stapler. I then closed the mesenteric defect with interrupted Surgidac sutures. I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic. I then put the patient in reverse Trendelenburg. I placed a liver retractor, identified, and dissected the angle of His. I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space. I fired transversely across the stomach with a 45 blue load stapler. I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch. I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil. I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler. I passed that in the end of my Roux limb and had the spike come out antimesenteric. I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag. I put some additional 2-0 Vicryl sutures in the anastomosis for further security. I then placed a bowel clamp across the bowel. I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch. I distended gastric pouch with air. There was no air leak seen. I could pass the scope easily through the anastomosis. There was no bleeding seen through the scope. We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason. I copiously irrigated out that incision with about 2 L of saline. I then closed the skin of all incisions with running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications.surgery, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1786
}
|
PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:, Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron. She was placed supine on the operating room table. General endotracheal anesthesia was induced without difficulty. In the holding area, her allergies were reviewed. It is unclear whether she is actually allergic to penicillin. Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine. She might be allergic to BACTRIM and SULFA. After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand. There was no bifid uvula or submucous cleft. She had 3+ cryptic tonsils with significant debris in the tonsillar crypts. Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume. The left superior tonsillar pole was then grasped with curved Allis forceps. _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3. Mouthgag was released, reopened, no bleeding was seen. The right tonsil was then removed in the same fashion. The mouthgag released, reopened, and no bleeding was seen. Small red rubber catheter in the nasal passage was used to retract the soft palate. She had mild-to-moderate adenoidal tissue residual. It was removed with Coblation Evac Xtra gently curved Wand on 9/5. Red rubber catheter was then removed. Mouthgag was again released, reopened, no bleeding was seen. Orogastric suction carried out with only scant clear stomach contents. Mouthgag was then removed. Teeth and lips were inspected and were in their preoperative condition. The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:, Family will be counseled postoperatively. Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain. _______ and promethazine if needed for nausea and vomiting.surgery, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1787
}
|
CHIEF COMPLAINT:, Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:, Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:, TURP.,MEDICATIONS:, Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:, None.,FAMILY HISTORY:, Hypertension.,SOCIAL HISTORY:, Significant for about a 20-pack-year tobacco use, quit in 1991. No ethanol use or illicit drug use. He is married. He has one dog at home. He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:, His weight has been steady over the years. Neck collar size is 17½". He denies any chest pain, cough, or shortness of breath. Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:, A pleasant, obese, African-American male in no apparent respiratory distress. T: 98. P: 90. RR: 20. BP: 156/90. O2 saturation: 97% on room air. Ht: 5' 5". Wt: 198 lb. HEENT: A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD. CARDIAC: Regular rate and rhythm without any adventitious sounds. CHEST: Clear lungs bilaterally. ABDOMEN: An obese abdomen with active bowel sounds. EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGIC: Non-focal.,IMPRESSION:,1. Probable obstructive sleep apnea syndrome.,2. Hypertension.,3. Obesity.,4. History of tobacco use.,PLAN:,1. We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2. Encouraged weight loss.,3. Check TSH.,4. Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5. Asked to return to the clinic one week after sleep the study is done.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1788
}
|
DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.obstetrics / gynecology, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1789
}
|
HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. Simulation films were obtained, documenting its positioning. The 3-dimensional treatment planning process was accomplished utilizing the CT derived data. A treatment plan was selected utilizing sequential dwell positions within a single catheter. The patient was taken to the treatment area. The patient was appropriately positioned and the position of the intracavitary device was checked. Catheter length measurements were taken. Appropriate measurements of the probe dimensions and assembly were also performed. The applicator was attached to the HDR after-loader device. The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication. The brachytherapy source was appropriately removed back to the brachytherapy safe within the device. Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty. The patient was in no apparent distress and was discharged home.hematology - oncology, geiger-muller, treatment planning, hdr brachytherapy, intracavitary, applicator, brachytherapyNOTE,: 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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1790
}
|
PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.surgery, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1791
}
|
HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicuspid aortic valve was also seen without insufficiency or stenosis. The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE: ,After sedation and general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place. There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle. A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery. The transverse arch measured 5 mm. Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level. The diaphragm measured 5.6 mm. The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery. This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist. Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient. Repeat angiogram showed mild improvement in degree of aortic narrowing. The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist. The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the pediatric intensive care unit in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to mild systemic arterial desaturation and anemia. There is no evidence of significant intracardiac shunt. Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta. The calculated flows were mildly increased. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels. There is discrete juxtaductal coarctation of the aorta. Flow within the intercostal arteries was retrograde. Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg. There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta. The calculated systemic flow fell to normal values. Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus. There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries. The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES: ,1. Juxtaductal coarctation of the aorta.,2. Dilated cardiomyopathy.,3. Bicuspid aortic valve.,4. Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference. The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery. The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months. The further cardiologic care will be directed by Dr. X.surgery, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1792
}
|
CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1793
}
|
PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux. The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration. He has failed outpatient antibiotic therapy and conservative methods. At this time, he desires to attempt surgical correction. The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone. He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively. The wound was on the planar medial, distal and dorsal medial. The wound's bases were fibrous. They did not break the bone at this point. They were each approximately 0.5 cm in diameter. After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied. Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block. Next, the foot was prepped and draped in the usual aseptic fashion. It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected. Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium. Next, the incision was deepened through the subcutaneous tissue. A heavy amount of bleeding was encountered. Therefore, a Penrose drain was applied at the tourniquet, which failed. Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis. Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery. Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon. The long extensor tendon was thickened and overall exhibited signs of hypertrophy. The transverse incision through the long extensor tendon was made with a #15 blade. Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint. Next, the extensor tendon was peeled dorsally and distally off the bone. Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx. This bone was removed with a sharp dissection. Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx. This was passed off as the infected bone specimen for microbiology and pathology. Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx. Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins. The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline. Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin. This bone was found to be hard and healthy appearing. The wound after irrigation was free of all debris and infected tissue. Therefore anaerobic and aerobic cultures were taken and sent to microbiology. Next, OsteoSet beads, tobramycin-impregnated, were placed. Six beads were placed in the wound. Next, the extensor tendon was re-approximated with #3-0 Vicryl. The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits. A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap. The patient tolerated the above anesthesia and procedure without complications. He was transported via a cart to the Postanesthesia Care Unit. His vitals signs were stable and vascular status was intact. He was given a medium postop shoe that was well-formed and fitting. He is to elevate his foot, but not apply ice. He is to follow up with Dr. X. He was given emergency contact numbers. He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home. The patient was discharged in stable condition.surgery, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1794
}
|
She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. She also has a history of glaucoma diagnosed in 1990 and macular degeneration. She has been followed in her home country and is here visiting family. She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day. She took both the drops this morning. She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye. Manifest refraction showed no improvement in either eye. The intraocular pressures by applanation were 7 on the right and 18 in the left eye. Gonioscopy showed grade 4 open angles in both eyes. Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes. The lids were normal OU. She has mild dry eye OU. The corneas are clear OU. The anterior chamber is deep and quiet OU. Irides appear normal. The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU. The optic nerves are normal in size. They both appear to have mild pallor. The optic cups in both eyes are shallow. The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye. In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy. I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage. She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye. In the left eye, she has also several high-risk drusen, but no evidence of neovascularization. The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild. I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard. She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye. The intraocular pressure in the mid-to-high teens in the left eye is probably high for her. She has allergic reaction to Cosopt. I will recommend starting Xalatan OS nightly. I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD. She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes. The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye. I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.consult - history and phy., cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1795
}
|
EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE: ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age. There are no extraaxial fluid collections. There is no hydrocephalus/midline shift. Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits. The normal vascular flow volumes are maintained. The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain. Specifically, no findings to explain the patient's headaches are identified.neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1796
}
|
PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.surgery, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1797
}
|
TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,ANESTHESIA:, General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:, 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was then inflated. Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon. The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the periosteum of the first left metatarsal. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft. Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact. The screws were sent to pathology for examination. The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification. The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding. The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy. Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished. The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft. Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent. The area was flushed copiously flushed with saline. The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material. All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time. The left ankle tourniquet was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels. The patient was given specific instructions and education on how to continue caring for his left foot surgery. The patient was also given pain medications, instructions on how to control his postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.surgery, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1798
}
|
The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.ophthalmology, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: 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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1799
}
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DIAGNOSES:,1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air.,GENERAL: She is sleeping and in no acute distress.,HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion.,CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep.,ABDOMEN: Normal bowel sounds. Soft and nondistended.,GENITOURINARY: She is Tanner I female.,DISCHARGE WEIGHT:, Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings.,DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:, Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,discharge summary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs,
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