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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3600
}
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CHIEF COMPLAINT:, Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:, A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema.,She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks.,PAST MEDICAL HISTORY:, Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:, She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis.,SOCIAL HISTORY:, The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California.,MEDICATIONS:, Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:, As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General: No fever, chills, or night sweats. Weight stable.,HEENT: No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes. No hearing changes or ear problems. No swallowing problems or mouth lesions.,Endocrine: Hypothyroidism but no polyuria or polydipsia. She watches her blood sugars. They have been doing quite well.,Respiratory: No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular: No chest pain or chest discomfort. No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI: As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better. She has had some irritable bowel syndrome and bowel abnormalities for years.,GU: No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. No vaginal bleeding or discharge.,Musculoskeletal: As above.,Hematological: She has had some anemia in the past.,Neurological: No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs: Weight is 164 pounds. Blood pressure: 140/64. Pulse: 72. Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General: A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT: Skull is normocephalic. TMs intact and shiny with good auditory acuity to finger rub. Pupils equal, round, reactive to light and accommodation with extraocular movements intact. Fundi benign. Sclerae and conjunctivae were normal.,Neck: No thyromegaly or cervical lymphadenopathy. Carotids are 2+ and equal bilaterally and no bruits present.,Lungs: Clear to auscultation and percussion with good respiratory movement. No bronchial breath sounds, egophony, or rales are present.,Heart: Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. PMI normal position. All pulses are 2+ and equal bilaterally.,Abdomen: Obese, soft with no hepatosplenomegaly or masses.,Breasts: No predominant masses, discharge, or asymmetry.,Pelvic Exam: Normal external genitalia, vagina and cervix. Pap smear done. Bimanual exam shows no uterine enlargement and is anteroflexed. No adnexal masses or tenderness. Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities: The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well. No real erythema. There is no real swelling of the knees. No new pedal edema.,Lymph nodes: No cervical, axillary, or inguinal adenopathy.,Neurological: Cranial nerves II-XII are grossly intact. Deep tendon reflexes are 2+ and equal bilaterally. Cerebellar and motor function intact in all extremities. Good vibratory and positional sense in all extremities and dermatomes. Plantar reflexes are downgoing bilaterally.,LABORATORY: ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. Urinalysis is within normal limits. Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1. Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. I think we need to look at this more closely.,2. Diarrhea that seems to have resolved. Whether this is related to the above is unclear.,3. Diabetes mellitus type II, really fairly well controlled.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3601
}
|
PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:, Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED: ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS: ,20 mL.,TUBES/DRAINS: ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: ,The patient is a 17-month-old boy with hypospadias abnormality. The plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. IV antibiotics were given. He was then placed in the supine position. The foreskin was retracted and cleansed. He was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed on the glans. The urethra was calibrated with the lacrimal duct probes to an 8-French. We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff. We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis. The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap. Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection. He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck. We repeated the artificial erection and the penis was straight. We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them. Using the curved iris scissors, we then also further mobilized the glanular wings. The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate. The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter. We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl. We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well. 5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans. Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans. Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff. On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place. IV Toradol was given at the procedure. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.surgery, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3602
}
|
PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS: ,Chronic renal failure.,PROCEDURE PERFORMED:, Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male presented to ABCD General Hospital on 08/30/2003 for evaluation of elevated temperature. He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated. He did require a short-term of Levophed for hypotension. He is felt to have an infected dialysis catheter, which was removed. He was planned to undergo replacement of his Perm-A-Cath, dialysis catheter, however, this was not possible. He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis. He was explained the risks, benefits, and complications of the procedure previously. He gave us informed consent to proceed.,OPERATIVE PROCEDURE: , The patient was placed in the supine position. The left inguinal region was shaved. His left groin was then prepped and draped in normal sterile fashion with Betadine solution. Utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine. Under direct aspiration technique, the left femoral vein was cannulated. Next, utilizing an #18 gauge Cook needle, the left femoral vein was cannulated. Sutures were removed, nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter. The needle was then removed. Utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter. Utilizing a #10 French dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the Seldinger guidewire. Dilator was removed and a preflushed circle-C 8 inch catheter was inserted over the Seldinger guidewire. The guidewire was retracted out from the blue distal port and grasped. The catheter was then placed in the left femoral vessel _______. This catheter was then fixed to the skin with #3-0 silk suture. A mesenteric dressing was then placed over the catheter site. The patient tolerated the procedure well. He was turned to the upright position without difficulty. He will undergo dialysis today per Nephrology.surgery, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3603
}
|
DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital. The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital. Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started. The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started. The patient did have labor epidural, which worked well. It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep. The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth. The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid. DeLee suctioning was performed at the perineum. A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl. The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.obstetrics / gynecology, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: 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": 3604
}
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HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night. He denies any pain, nausea, vomiting or diarrhea. In the ER, a Foley catheter was placed and was irrigated with saline. White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9. Urine culture is pending. Chest x-ray is pending. His UA did show lots of red cells. The patient currently is comfortable. CBI is running. His urine is clear.,PAST MEDICAL HISTORY:,1. Hypertension.,2. High cholesterol.,3. Bladder cancer.,4. Bilateral total knee replacements.,5. Cataracts.,6. Enlarged prostate.,ALLERGIES:, SULFA.,MEDICATIONS AT HOME:,1. Atenolol.,2. Cardura.,3. Zegerid.,4. Flomax.,5. Levaquin.,6. Proscar.,7. Vicodin.,8. Morphine.,9. Phenergan.,10. Ativan.,11. Zocor.,12. Prinivil.,13. Hydrochlorothiazide.,14. Folic acid.,15. Digoxin.,16. Vitamin B12.,17. Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter. He does not smoke, occasionally drinks alcohol. He is independent with his activities of daily living.,REVIEW OF SYSTEMS:, Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL: An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS: BP of 162/60 and pulse oximetry of 98% on room air.,HEENT: Pink conjunctivae. Anicteric sclerae. Oral mucosa is moist.,NECK: Supple.,CHEST: Clear to auscultation.,HEART: Regular S1 and S2.,ABDOMEN: Soft and nontender to palpation.,EXTREMITIES: Without edema.,He has a Foley catheter in place. His urine is clear.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Hematuria.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3605
}
|
MALE PHYSICAL EXAMINATION,HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate.,NECK: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no jugular venous distention.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm without S3, S4. No murmurs or rubs are appreciated.,ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. No masses, hepatomegaly or splenomegaly are appreciated.,GU: Normal **circumcised male. No discharge or hernias. No testicular masses.,RECTAL EXAM: Normal rectal tone. Prostate is smooth and not enlarged. Stool is Hemoccult negative.,EXTREMITIES: Reveal no clubbing, cyanosis, or edema. Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM: Reveals no tenosynovitis.,NEUROLOGIC: Cranial nerves II through XII are grossly intact. Motor strength is 5/5 and equal in all four extremities. Deep tendon reflexes are +2/4 and equal bilaterally. Patient is alert and oriented times 3.,PSYCHIATRIC: Grossly normal.,DERMATOLOGIC: No lesions or rashes.consult - history and phy., male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3606
}
|
PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3. Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted @ L45 nerve root on the left side. After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be @ L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.) The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction.radiology, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3607
}
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CHIEF COMPLAINT:, Ankle pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to move or bear weight. No other injuries noted. He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above. Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:emergency room reports, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3608
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered.consult - history and phy., x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3609
}
|
EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.orthopedic, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3610
}
|
HISTORY:, A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs: Pulse of 90 and blood pressure 150/70.,Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest: Clinically clear.,Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending. Her electrolytes revealed sodium of 135 and potassium of 3.2. Her potassium was switched to K-Dur 40 mEq twice a day. Her blood chemistries are otherwise closely monitored. INRs were obtained and were therapeutic. Throughout her hospitalization, multiple cultures were also obtained. Urine cultures grew Klebsiella. She was treated with appropriate antibiotics. Her detailed blood work is as in the chart. Detailed radiological studies are as in the chart. The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1. Atherosclerotic heart disease, status post coronary artery bypass graft.,2. Valvular heart disease, status post aortic valve replacement.,3. Right arm arterial thrombosis, status post amputation right lower arm.,4. Hypothyroidism.,5. Uncontrolled diabetes mellitus, type 2.,6. Urinary tract infection.,7. Hypokalemia.,8. Heparin-induced thrombocytopenia.,9. Peripheral vascular occlusive disease.,10. Paroxysmal atrial fibrillation.,11. Hyperlipidemia.,12. Depression.,13. Carotid stenosis.consult - history and phy., arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3611
}
|
PREOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE: ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure. A speculum was placed into the vagina. A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix. The uterus was sounded to 10.5 cm. A #10 RUMI cannula was utilized and attached for uterine manipulation. The single-tooth tenaculum and speculum were removed from the vagina. At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity. Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide. After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity. Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted. At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine. A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation. Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular. The fallopian tubes have been previously interrupted surgically. The ovaries appeared normal bilaterally. The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions. The ureters were noted to be deep in the pelvis. At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty. The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. A similar procedure was carried out on the left with the left uterine cornu identified. The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected. The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection. At this time, attention was made to the vaginal hysterectomy. The laparoscope was removed and attention was made to the vaginal hysterectomy. The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum. A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio. A circumferential incision was then made at the cervicovaginal portio. The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty. The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures. The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture. The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally. The uterus was then removed and passed off the operative field. Laparotomy pack was placed into the pelvis. The pedicles were evaluated. There was no bleeding noted; therefore, the laparotomy pack was removed. The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures. The vaginal cuff was then closed in a running fashion with #0 Vicryl suture. Hemostasis was noted throughout. At this time, the laparoscope was reinserted into the abdomen. The abdomen was reinsufflated. Evaluation revealed no further bleeding. Irrigation with sterile water was performed and again no bleeding was noted. The suprapubic trocar sheath was then removed under laparoscopic visualization. The laparoscope was removed. The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed. The skin incisions were closed with #4-0 Vicryl in subcuticular fashion. Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition. Estimated blood loss was approximately 100 mL. There were no complications. The instrument, sponge, and needle counts were correct.surgery, abnormal uterine bleeding, laparoscopic-assisted vaginal hysterectomy, uterine fibroids, bipolar electrocautery, vaginal hysterectomy, vicryl sutures, tooth, uterine, uterosacral, laparoscope, electrocautery, hysterectomy, laparoscopic, coagulated, vaginal, ligament, transected
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3612
}
|
REASON FOR CONSULTATION:, Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:, Not contributory.,PHYSICAL EXAMINATION:,GENERAL: Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact.,NECK: Supple. Trachea is midline.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds.,EXTREMITIES: No clubbing, edema, or cyanosis.,SKIN: The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:, As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:, At this time, the CT Surgery service has been consulted and has left recommendations. The patient also is awaiting bronchoscopy per the Pulmonary Service. At this time, there are no General Surgery issues.cardiovascular / pulmonary, trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3613
}
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PROCEDURE PERFORMED:, Cervical epidural steroid injection, C5-6.,ASSISTANT:, None.,ANESTHESIA:, Local.,DETAILS OF PROCEDURE: , The patient was brought to the operating theater and placed prone onto the radiolucent table. Subsequent monitored anesthesia care was administered. The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level. The neck area was then prepped with Betadine solution and draped sterile. A metallic marker was placed over the C5-6 lamina and a skin wheal was raised in the skin. A #20-gauge Tuohy needle was then advanced into the spinal canal using 1% Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined. The needle was redirected into the interlaminar space and advanced to the previously determined level. A 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space. When a free flow of air was produced, a solution of 80 mg Depo-Medrol, 2 cc of 1% Xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space. The Tuohy needle was removed. Betadine was cleansed from the skin. A bandage was placed over the needle entrance point. The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia. The patient was taken to the recovery room in stable condition.pain management, c-arm, cervical epidural steroid injection, ap view, lumbar spine, tuohy needle, epidural steroid, steroid injection
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3614
}
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REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:, The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history. She denies any orthopnea or paroxysmal nocturnal dyspnea. Denies any edema, chest pain, palpitations, or syncope. She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:, Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1. Acidophilus supplement.,2. Cholestyramine.,3. Creon 20 three times daily.,4. Diovan 160 mg twice daily.,6. Lantus 10 daily.,7. Norvasc 5 mg daily.,8. NovoLog 70/30, 10 units at 12 noon daily.,9. Pamelor 15 mL every evening.,10. Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY: ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease. The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills. She has also had some jaundice. Denies any nausea or vomiting. Denies any chest pain or abdominal pain. Denies orthopnea, paroxysmal nocturnal dyspnea or edema. She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits. Denies melena or hematochezia. All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL: An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS: Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK: Her head is atraumatic. She is normocephalic. Her neck is supple. There is no JVD. No palpable adenopathy or thyromegaly. There is some icterus of the sclerae bilaterally. Oral mucosa is moist.,CHEST: Symmetrical expansion with normal percussion note. There are no inspiratory crackles or expiratory wheeze.,CARDIAC: Heart sounds S1 and S2 are regular. There is a 2/6 systolic murmur heard through the precordium. There is no gallop or rub. There is no palpable thrill or retrosternal lift.,ABDOMEN: Soft, nondistended, and nontender with normal bowel sounds. No audible bruits.,EXTREMITIES: No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC: She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43. White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000. Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction. Previous biliary stent was present.,EKG shows normal sinus rhythm. There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur. No previous history of heart disease. This murmur has occurred in the setting of fever and bacteremia. The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN: ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms. Blood pressure control should be maintained with Diovan and Norvasc. Potassium should be replaced, and hyponatremia should be on proactive.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3615
}
|
PROCEDURE PERFORMED,1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.cardiovascular / pulmonary, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: 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": 3616
}
|
ADMITTING DIAGNOSIS:, Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1. Aftercare following surgery for injury and trauma.,2. Decubitus ulcer, lower back.,3. Alcohol induced persisting dementia.,4. Anemia.,5. Hypokalemia.,6. Aftercare healing traumatic fracture of the lower arm.,7. Alcohol abuse, not otherwise specified.,8. Aftercare healing traumatic lower leg fracture.,9. Open wound of the scalp.,10. Cervical disk displacement with myelopathy.,11. Episodic mood disorder.,12. Anxiety disorder.,13. Nervousness.,14. Psychosis.,15. Generalized pain.,16. Insomnia.,17. Pain in joint pelvic region/thigh.,18. Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:, None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE: ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident. He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury. When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm. He had a brace placed in the left leg for his left tibial plateau fracture. He was confused initially and initially started on rehab. He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. He did well from orthopedic standpoint. He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. He made slow progress from therapy. His confusion gradually cleared. He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this. He did require some Ativan for agitation. He was on chronic pain medications as an outpatient. His medications were adjusted here and he did well with this as well. The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. We did have orthopedic followup. He was taken out of his right leg brace the week of 06/16/2008. He did well with therapy. Overall, he was doing much and much better. He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better. He was using a wheeled walker. He was able to bear weight on his left leg. His pain level had been well controlled and his moods had improved dramatically. He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1. Calcium with vitamin D 1 tablet twice a day.,2. Ferrous sulfate 325 mg t.i.d.,3. Multivitamin 1 daily.,4. He was on nicotine patch 21 mg per 24 hour.,5. He was on Seroquel 25 mg at bedtime.,6. He was on Xenaderm for his sacral pressure ulcer.,7. He was on Vicodin p.r.n. for pain.,8. Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3617
}
|
CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest. Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region. There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm. A subcarinal lymph node is enlarged also. It measures 6 x 2 cm. Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura. There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm. There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit. The liver parenchyma is normal without evidence of any dominant masses. The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1. Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2. Extensive mediastinal adenopathy as described above.,3. No lesion seen within the left lung at this time.,4. Supraclavicular adenopathy.cardiovascular / pulmonary, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3618
}
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REASON FOR VISIT:, Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,general medicine, medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3619
}
|
CHIEF COMPLAINT:, Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:, This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea.,PHYSICAL EXAM:,General: He is alert in no distress.,Vital Signs: Temperature: 99.1 degrees.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,ASSESSMENT:,1. Right otitis media.,2. Right otorrhea.,PLAN:, Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup.consult - history and phy., drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3620
}
|
DIAGNOSIS:, Stasis ulcers of the lower extremities,OPERATION:, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:, This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the order of 50% or more of the circumference of her lower leg. They were in a distribution to be consistent with stasis ulcers. They were granulating nicely and she was scheduled for surgery.,FINDINGS:, Large ulcers of lower extremities with size as described above. These are irregular in shape and posterior and laterally on the lower legs. There was no evidence of infection. The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes. The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin. The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed. Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch. This was meshed 1:1.5 and then stapled into position on the wounds. The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels. The donor site was dressed with Op-Site. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3621
}
|
CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3622
}
|
TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. Recommendation was for an Ommaya reservoir. Risks and benefits have been explained. They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS: ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest. The right frontal region was prepped and draped in the usual sterile fashion. Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line. Once this was completed, a burr hole was then created with a high-speed burr. The dura was then coagulated and opened. The Ommaya reservoir catheter was inserted up to 6.5 cm. There was good flow. This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision. This was then cut and __________. It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies. Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin. The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.neurosurgery, caprosyn, leukemic meningitis, ommaya reservoir, leukemia, meningeal, intrathecal, chemotherapy, leukemic, meningitis, ommaya,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3623
}
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TITLE OF OPERATION:,1. Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2. Weil osteotomy with internal screw fixation, first right metatarsal.,3. Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1. Bunion deformity, right foot.,2. Dislocated second right metatarsophalangeal joint.,3. Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1. Bunion deformity, right foot.,2. Dislocated second right metatarsophalangeal joint.,3. Hammertoe deformity, second right digit.,ANESTHESIA:, Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES: ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size. One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites. The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg. The right foot was then prepped, scrubbed, and draped in a normal sterile technique. The right ankle tourniquet was then inflated. Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe. 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 capsule and the periosteum of the first right metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint. Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw. The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal. The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation. The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal. Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws. The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy. The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique. One screw measured 16 mm, second screw measured 18 mm in length. Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed. Fixation of the osteotomy was found to be excellent. The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw. To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally. Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system. Upon insertion of the screw, using AO technique, the wire was removed. The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe. Fixation of the osteotomy was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical. Range of motion of that joint was uninhibited. The area was flushed copiously with saline. Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision. Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped and cauterized. The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal. The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw. Upon insertion of the screw, using AO technique, the wire was then removed. Fixation of the osteotomy with 2.0 screw was found to be excellent. The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced. Range of motion of the second right metatarsophalangeal joint was found to be excellent. Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues. Then, 4-0 Vicryl was used to approximate the skin incision. Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint. The island of skin between the two semi-elliptical incisions was resected in toto. The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint. A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed. Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected. The area was copiously flushed with saline. The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe. A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions. Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical. At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's right ankle tourniquet was deflated, time was 60 minutes. Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels. The patient was given instructions and education on how to continue caring for her right foot surgery. 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 her first postoperative appointment.surgery, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3624
}
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PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. The patient is also diabetic. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored. There was no evidence of any peritoneal studding or masses. The abdomen was otherwise within normal limits. The gallbladder was easily visualized. There was an intrahepatic gallbladder. There was no evidence of any inflammatory change.,PROCEDURE:, After informed written consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. Next, an infraumbilical incision was made with a #10 scalpel. The skin was elevated with towel clips and a Veress needle was inserted. The abdomen was then insufflated to 15 mmHg of pressure. The Veress needle was removed and a #10 blade trocar was inserted without difficulty. The laparoscope was then inserted through this #10 port and the abdomen was explored. There was no evidence of any peritoneal studding. The peritoneum was smooth. The gallbladder was intrahepatic somewhat. No evidence of any inflammatory change. There were no other abnormalities noted in the abdomen. Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. Using a curved dissector, the cystic duct was identified and freed up circumferentially. Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct. The cystic artery was transected in similar fashion. Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. It was done without difficulty. The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. Hemostasis was maintained using electrobovie cautery. The liver bed was then copiously irrigated and aspirated. All the fluid and air was then aspirated and then all ports were removed under direct visualization. The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle. The skin was closed with a running subcuticular #4-0 undyed Vicryl. 0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition.surgery, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3625
}
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CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis. On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells. Her iron levels were 5 and her percent transferrin was 2. There was no evidence of hemolysis. Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth. She currently has an IUD, so she is not menstruating. She was discharged from the hospital on iron supplements. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:, As per the HPI, otherwise negative.,PAST MEDICAL HISTORY: ,She is status post birth of a baby girl 5 months ago. She is G1, P1. She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use. She has rare alcohol use. No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer. There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:consult - history and phy., trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3626
}
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PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,3. Hemoperitoneum.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Right salpingectomy.,4. Lysis of adhesions.,5. Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:, Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile. No adnexal masses, however, were appreciated on the bimanual exam. Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus. There were also adhesions to the left fallopian tube and the right fallopian tube. There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood. There was some questionable gestational tissue ________ on the left sacrospinous ligament. There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:, After an informed consent was obtained, the patient was taken to the operating room and the 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. A weighted speculum was then placed in the vagina. The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology. At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed. Next, attention was then turned to the abdomen. The surgeons all are removed the dirty gloves in the previous portion of the case. Next, a 2 cm incision was made immediately inferior to umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision. Next, a syringe was used to inject normal saline into the Veress needle. The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting. The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting. The abdomen was insufflated to an adequate distension. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted. Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera. A Veress needle and a step sheath were inserted through this incision. Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization. Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion. A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization. The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes. Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen. Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port. Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy. An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy. This was then sent to the pathology. Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic. The abdomen was further irrigated. The liver was examined and appeared to be within normal limits. At this point, the two size #5 ports and a size #12 port were removed under direct visualization. The camera was then removed. The CO2 gas was disconnected and the abdomen was desufflated. The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit. All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion. They were then steri-stripped and bandaged appropriately. At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She was discharged home with a postoperative hemoglobin of 8.9. She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain. She will follow up within a week in the OB resident clinic.surgery, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3627
}
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HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night. He denies any pain, nausea, vomiting or diarrhea. In the ER, a Foley catheter was placed and was irrigated with saline. White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9. Urine culture is pending. Chest x-ray is pending. His UA did show lots of red cells. The patient currently is comfortable. CBI is running. His urine is clear.,PAST MEDICAL HISTORY:,1. Hypertension.,2. High cholesterol.,3. Bladder cancer.,4. Bilateral total knee replacements.,5. Cataracts.,6. Enlarged prostate.,ALLERGIES:, SULFA.,MEDICATIONS AT HOME:,1. Atenolol.,2. Cardura.,3. Zegerid.,4. Flomax.,5. Levaquin.,6. Proscar.,7. Vicodin.,8. Morphine.,9. Phenergan.,10. Ativan.,11. Zocor.,12. Prinivil.,13. Hydrochlorothiazide.,14. Folic acid.,15. Digoxin.,16. Vitamin B12.,17. Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter. He does not smoke, occasionally drinks alcohol. He is independent with his activities of daily living.,REVIEW OF SYSTEMS:, Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL: An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS: BP of 162/60 and pulse oximetry of 98% on room air.,HEENT: Pink conjunctivae. Anicteric sclerae. Oral mucosa is moist.,NECK: Supple.,CHEST: Clear to auscultation.,HEART: Regular S1 and S2.,ABDOMEN: Soft and nontender to palpation.,EXTREMITIES: Without edema.,He has a Foley catheter in place. His urine is clear.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Hematuria.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3628
}
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PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:, Incompetent glottis.,OPERATION PERFORMED:,1. Fat harvesting from the upper thigh.,2. Micro-laryngoscopy.,3. Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion. A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space. After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin. After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device. Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. Estimated blood loss was negligible.ent - otolaryngology, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3629
}
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HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease. His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him. I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes. On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control. He has also brought a machine at home, and states his blood pressure readings have been better. He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past. He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative. He continues to feel well. He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1. Vytorin 10/40 mg one a day.,2. Rocaltrol 0.25 micrograms a day.,3. Carvedilol 12.5 mg twice a day.,4. Cozaar 50 mg twice a day.,5. Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings. GENERAL: He is a thin African American gentleman in no distress. LUNGS: Clear. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. I did not appreciate a murmur. ABDOMEN: Soft. He has a very soft systolic murmur at the left lower sternal border. No rubs or gallops. EXTREMITIES: No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9. He is not on EPO yet. His UA has been negative.,IMPRESSION:,1. Chronic kidney disease, stage IV, secondary to polycystic kidney disease. His estimated GFR is 16 mL per minute. He has no uremic symptoms.,2. Hypertension, which is finally better controlled.,3. Metabolic bone disease.,4. Anemia.,RECOMMENDATION:, He needs a number of things done in terms of followup and education. I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes. I also gave him websites that he can get on to find out more information. I have not made any changes in his medications. He is getting blood work done prior to his next visit with me. I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05. He will see me back in about 4 to 6 weeks.soap / chart / progress notes, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3630
}
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PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,6. Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7. Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:, Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section. The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm. The decision for C-section was made.,PROCEDURE:, The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision. The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors. The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically. The abdominal rectus muscle was divided in the center and extended in a vertical fashion. Peritoneum was entered at a high point and extended in a vertical fashion as well. The bladder blade was put in place. The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally. The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus. The first fetus was vertex. The fluid was clear. The head was delivered followed by the remaining portion of the body. The cord was doubly clamped and cut. The newborn handed off to waiting pediatrician and nursery personnel. The second fluid was ruptured. It was the clear fluid as well. The presenting part was brought down to be vertex. The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel. Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology. At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection. Then, there were multiple omental adhesions on the surface of the uterus itself. This needed to be released as well as on the abdominal wall and then the uterus could be externalized. The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first. The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath. The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized. The same technique was completed on the left side with the knuckle portion cut off and cauterized as well. The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis. Interceed was placed over this area as well. The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood. The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges. The abdominal rectus muscle was irrigated. The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center. The subcutaneous tissue was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue. Skin edges were re-approximated with sterile staples. Sterile dressing was applied. Uterus was evacuated of any remaining blood vaginally. The patient was taken to the recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.obstetrics / gynecology, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3631
}
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HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improvement of her symptoms. The nursing home did not do a voiding diary. She is accompanied by her power of attorney. No dysuria, gross hematuria, fever or chills. No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION: ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. This has not improved on VESIcare as well as Enablex. Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure. The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today. Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided. They will see Dr. X with a prior voiding diary, which is again discussed. All questions answered.,PLAN:, As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney. In the meantime, Sanctura prescription is provided, and voiding diaries are provided. All questions answered.soap / chart / progress notes, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3632
}
|
PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL: ,Following induction of adequate general anesthetic, the patient was positioned for surgery. She was placed in a lateral position and her head was maintained with Mayfield pins. The left periauricular area was shaved, prepped, and draped in the sterile fashion. Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified. The proposed incision was injected with 1% Xylocaine with epinephrine. Next, T-shaped incision was made approximately 5 cm behind the postauricular crease. The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. Bergen retractors were used to maintain exposure. Using a cutting bur with continuous suction and irrigation of craniotomy was performed. The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. From these structures approximately 4 x 4 cm, a window of bone was removed. Bone shavings were collected during the dissection and placed in Siloxane suspension for later use. The bone flap was also left at the site for further use. Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. Bone wax was used to occlude air cells lateral to the sigmoid sinus. There was extensively aerated temporal bone. At this point, Dr. Trask entered the case in order to open the dura and expose the tumor. The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. The dura was excised from around the porous acusticus extending posteriorly along the bone. Then, using diamond burs, the internal auditory canal was dissected out. The bone was removed laterally for distance of approximately 8 mm. There was considerable aeration around the internal auditory canal as well. The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. The eighth nerve was identified and transected. Tumor debulking allowed for retraction of the tumor capsule away from the brainstem. The facial nerve was difficult to identify at the brainstem as well. It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. Attention was then redirected to the internal auditory canal where this portion of the tumor was removed. The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. At this point, plane of dissection was again indistinct. The tumor had been released from the porous and could be rotated. The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. The nerve could be stimulated, but was quite splayed over the anterior face. Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. However, the cerebellopontine angle portion of the nerve was not usually delineated. However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness. It was released from the brainstem ventrally. The tumor was then cauterized with bipolar electrocautery. The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. Overall, the remaining tumor volume would be of small percentage of the original volume. At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis. The air cells around the internal auditory canal were packed off with muscle and bone wax. A piece of fascia was then laid over the bone defect. Next, the dura was closed with DuraGen and DuraSeal. The bone flap and bone ***** were then placed in the bone defect. Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures. The skin was also closed using interrupted subdermal 3-0 Vicryl sutures. Running 4-0 nylon suture was placed at the skin levels. Sterile mastoid dressing was then placed. The patient tolerated the procedure well and was transported to the PACU in a stable condition. All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS: ,100 mL.neurosurgery, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3633
}
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PREOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:, Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:, Topical.,COMPLICATIONS:, None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision. They were found to have a visually significant cataract. The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the operating room. A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion. A paracentesis was created at ** o'clock. The anterior chamber was filled with Viscoat. A clear corneal incision was made at ** o'clock with the 3-mm diamond blade. A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps. The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag. The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion. The residual cortex was removed with the irrigation/aspiration handpiece. The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well. The residual Provisc was removed with the irrigation/aspiration handpiece. The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution. The wounds were found to be free from leak. Zymar and Pred Forte were instilled postoperatively. The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications. He will follow up with us in one day.ophthalmology, nuclear sclerotic cataract, intraocular lens, cataract, kelman phacoemulsification, sclerotic cataract, posterior chamber, capsular bag, eye, anesthesia, phacoemulsification
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3634
}
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PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1. Lumbar discogram L2-3.,2. Lumbar discogram L3-4.,3. Lumbar discogram L4-5.,4. Lumbar discogram L5-S1.,ANESTHESIA: ,IV sedation.,PROCEDURE IN DETAIL: ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.surgery, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3635
}
|
PREOPERATIVE DIAGNOSIS:, Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital. The following sizes of NexGen system were utilized: E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had undergone two knee arthroscopies in the years preceding this. They were performed by myself. She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live. Medial compartment had minor changes present. There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides. There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE: ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department. Thigh tourniquet was placed upon the patient's right leg. She was prepped and draped in the usual sterile manner. The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time. A straight incision was carried down through the skin and subcutaneous tissue. Hemostasis was controlled with electrocoagulation. Medial parapatellar arthrotomy was created and the knee cap was everted. The ligaments were balanced. A portion of the fat pad was removed and the ACL was completely removed. Drill hole was made in the distal femur. The size to an E, right. Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side. This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made. Intramedullary guide was then placed, pegged, and anterior cut carried out. There was excellent resection. It was flat. Distal cutting guide was then placed in five degrees of valgus. Appropriate cuts were carried out. The standard cut was utilized.,The finishing guide for E was held with pins as well as screws. Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made. The cutting guide was then removed. The bone was removed. Excess bone was taken out posteriorly. The posterior capsule was loosened up. There were two different fabellas in the posterolateral compartment and they were loosened. Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner. An extramedullary tibial cutting guide was then placed, pinned, and held. A cut was carried out parallel to the foot. Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges. Trial range of motion was satisfactory. It was necessary to perform a lateral retinacular release to the patella. The patella was isolated. Approximately 10 mm to 11 mm were reamed off. The size to 32 mm button and drill hole guide was placed, impacted, and drilled. Trial range of motion was satisfactory. The tibial guide was then pinned. Drill hole was placed, broached, and utilized. Copious irrigation was carried out. Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella. The implants were sequentially placed in tibia to femur to patella. Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed. There was excellent ligament balancing. A separate portal was utilized for subcutaneous drain. Tourniquet was deflated and hemostasis was controlled with electrocoagulation. Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin. Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing. Digits were pink and warm with brawny pulses distally at the end of the case. The patient was then transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair.orthopedic, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3636
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Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General: Pleasant, brighter.,Vital signs: 117/78, 12, 56.,Abdomen: Soft, nontender. Bowel sounds normal.,ASSESSMENT AND PLAN:,1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2. CAD/angina. See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,office notes, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3637
}
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CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a "whistle." In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.radiology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, neurology, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3638
}
|
PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS: ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:, 50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today. A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy. No heart tones were visible. On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated. These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient. After discussion of these options, the patient opted for a suction, dilation, and curettage. The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation. Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty. The patient was prepped and draped in usual sterile fashion in lithotomy position. A weighted speculum was placed. The anterior lip of the cervix was grasped with a single tooth tenaculum. At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus. Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted. At this time, the suction curette was advanced one additional time to suction any remaining products. All instruments were removed. Hemostasis was visualized. The patient was stable at the completion of the procedure. Sponge, lap, and instrument counts were correct.obstetrics / gynecology, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3639
}
|
PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: ,Gallbladder.,BRIEF HISTORY: ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture. The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department. Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure. The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain. During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder. The patient did well postdrainage. The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp. However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003. A HIDA scan had been performed, which showed no cystic duct obstruction. A tube cholecystogram was performed, which showed no cystic or common duct obstruction. There was abnormal appearance of the gallbladder, however, the pathway was patent. Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy. Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS: ,The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family. The patient was brought to the operating room after an epidural was performed per anesthesia. Local anesthesia was given with 1% lidocaine. A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel. Next, hemostasis was obtained using electro Bovie cautery. Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel. Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered . The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view. Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified. The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors. The cystic duct was identified. A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors. The gallbladder was then removed from the liver bed using electro Bovie cautery. A plane was created. The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel. The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections. Permanent sections are still pending. The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen. The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.surgery, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3640
}
|
EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home.radiology, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3641
}
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PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood.neurology, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3642
}
|
SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.,CHEST: There is prolonged expiration.,CARDIOVASCULAR: First and second heart sounds are heard. No murmur was appreciated.,ABDOMEN: Soft and nontender. Bowel sounds are positive.,EXTREMITIES: He has 2+ pedal swelling.,NEUROLOGIC: The patient is asleep, but easily arousable.,LABORATORY DATA:, PTT is 49. INR is pending. BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8. AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia. Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1. Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction. Continue current treatment as per Cardiology. We will consider adding ACE inhibitors as renal function improves.,2. Acute pulmonary edema, resolved.,3. Rapid atrial fibrillation, rate controlled. The patient is on beta-blockers and digoxin. Continue Coumadin. Monitor INR.,4. Coronary artery disease with ischemic cardiomyopathy. Continue beta-blockers.,5. Urinary tract infection. Continue Rocephin.,6. Bilateral perfusion secondary to congestive heart failure. We will monitor.,7. Chronic obstructive pulmonary disease, stable.,8. Abnormal liver function due to congestive heart failure with liver congestion, improving.,9. Rule out hypercholesterolemia. We will check lipid profile.,10. Tobacco smoking disorder. The patient has been counseled.,11. Hyponatremia, stable. This is due to fluid overload. Continue diuresis as per Nephrology.,12. Deep venous thrombosis prophylaxis. The patient is on heparin drip.soap / chart / progress notes, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3643
}
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REASON FOR CONSULTATION:, Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:, Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. Her hemoglobin was 13.3 with white count of 11.8 at that time. Her lymphocyte count was 6.7. The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000. She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes. Platelet count was 38. Her rapid strep screen was negative but the infectious mononucleosis screen is positive. The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May. She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that. The patient continues to have sore throat.,She denies any history of epistaxis. Denies any history of gum bleeding. The patient denies any history of petechiae. She denies any history of abnormal bleeding. Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:, Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional: The history of fever about 2 weeks ago.,HEENT: Complains of some difficulty in swallowing.,Cardiovascular: Negative.,Respiratory: Negative.,Gastrointestinal: No nausea, vomiting, or abdominal pain.,Genitourinary: No dysuria or hematuria.,Musculoskeletal: Complains of generalized body aches.,Psychiatric: No anxiety or depression.,Neurologic: Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION: ,She was not in any distress. She appears her stated age. Temperature 97.9. Pulse 84. Blood pressure was 110/60. Weighs 162 pounds. Height of 61 inches. Lungs - Normal effort. Clear. No wheezing. Heart - Rate and rhythm regular. No S3, no S4. Abdomen - Soft. Bowel sounds are present. No palpable hepatosplenomegaly. Extremities - Without any edema, pallor, or cyanosis. Neurological: Alert and oriented x 3. No focal deficit. Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla. Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1. I had a long discussion with family regarding the treatment of ITP. In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2. An ultrasound of the abdomen will be performed tomorrow.,3. I have given her a requisition to obtain some blood work tomorrow.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3644
}
|
PREOPERATIVE DIAGNOSIS:, Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:, Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:, The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted. She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments. During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap. There was no evidence of intraperitoneal spread or lymphadenopathy. ,OPERATIVE PROCEDURE: ,The patient was brought to the Operating Room with an IV in place. Anesthetic was administered after which she was examined under anesthesia. The vagina was then prepped and a Foley catheter was placed. She was prepped and draped. A Pfannenstiel incision was made three centimeters above the symphysis pubis. The peritoneum was entered and the abdomen was explored with findings as noted. The Bookwalter retractor was placed, and bowel was packed. Clamps were placed on the broad ligament for traction. The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments. The round ligaments were isolated, divided and ligated. The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection. The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension. The utero-ovarian ligaments were then isolated, divided and doubly ligated. Tubes and ovaries were mobilized. The ureters were dissected free from the medial leaf of the peritoneum. When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated. The uterine artery pedicle was dissected anteriorly over the ureter. The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated. This was continued until the insertion point of the ureter into the bladder trigone. The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened. Clamps were placed on the uterosacral ligaments at their point of origin. Tissues were divided and suture ligated. Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated. The vagina was then clamped and divided at the junction between the middle and upper third. The vaginal vault was closed with interrupted figure-of-eight stitches. Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy. The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially. The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection. Ligaclips were applied where necessary. After removal of the lymph node specimens, the pelvis was irrigated. The ovaries were transposed above the pelvic brim using running stitches. Packs and retractors were removed, and peritoneum was closed with a running stitch. Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture. Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch. Skin was closed with a running subcuticular stitch. Final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.obstetrics / gynecology, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3645
}
|
SUBJECTIVE:, Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestion has continued to be very thick and purulent. It has never really resolved. He has a loose, productive-sounding cough but not consistently and not keeping him up at night. No wheezing or shortness of breath.,PAST MEDICAL HISTORY:, He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General: The patient is a 5-year-old male. Alert and cooperative. No acute distress.,Neck: Supple without adenopathy.,HEENT: Ear canals clear. TMs, bilaterally, have distorted light reflexes but no erythema. Gray in color. Oropharynx pink and moist with a lot of postnasal discharge. Nares are swollen and red. Thick, purulent drainage. Eyes are a little puffy.,Chest: Respirations regular, nonlabored.,Lungs: Clear to auscultation throughout.,Heart: Regular rhythm without murmur.,Skin: Warm, dry, pink. Moist mucus membranes. No rash.,ASSESSMENT:, Ongoing purulent rhinitis. Probable sinusitis and serous otitis.,PLAN:, Change to Omnicef two teaspoons daily for 10 days. Frequent saline in the nose. Also, there was some redness around the nares with a little bit of yellow crusting. It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart. Use a little Neosporin for now.consult - history and phy., ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3646
}
|
CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92.neurology, sellar, hct, htn, pituitary, aneurysm, brain ct, cataclysmic, coronary artery disease, headache, intracranial mass, loss of vision, mass, melanoma, palsy, sneeze, stroke, temporal arteritis, vision loss, bilateral babinski signs, sellar enlargement, pituitary mass, temporal, vision,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3647
}
|
PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea. ,POSTOPERATIVE DIAGNOSIS: ,Antibiotic-associated diarrhea. ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago. She has been having difficulty since that time with intermittent diarrhea and abdominal pain. She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes. She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE: , The risks and benefits of colonoscopy were explained to the patient in detail. She provided her consent. The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite. She was placed in the left lateral decubitus position. In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl. A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure. This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided. In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure. While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse. In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk. For this reason, the procedure was aborted at the level of the hepatic flexure. She was noted to have some pools of stool. This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes. Additionally, random biopsies were performed of the colon itself. It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum. However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome. The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:, She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures. She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum. She may also benefit from an antispasmodic and/or anxiolytic. Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.gastroenterology, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3648
}
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NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized. A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic. A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome. A 5- to 5.5-mm anterior capsulorrhexis was created. The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag. The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique. Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification. Peripheral cortex was removed with the irrigation and aspiration handpiece. The posterior capsule was polished. The capsular bag was expanded with viscoelastic. The implant was inspected under the microscope and found to be free of defects. The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag. The trailing haptic was positioned with the cartridge system. Residual viscoelastic was removed from the anterior chamber and from behind the implant. The corneal wound was hydrated with balanced salt solution. The anterior chamber was fully re-formed through the side-port incision. The wound was inspected and found to be watertight. The intraocular pressure was adjusted as necessary. The lid speculum was removed. Topical Timoptic drops, Eserine and Dexacidin ointment were applied. The eye was shielded. The patient appeared to tolerate the procedure well and left the operating room in stable condition. Followup appointment is with Dr. X on the first postoperative day.ophthalmology, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: 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": 3649
}
|
ADMISSION DIAGNOSES: ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED: ,Hemiarthroplasty, right hip.,CONSULTATIONS: ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip. The patient was admitted to Orthopedics and consulted Medicine. The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence. The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's. Brief elevation of white count following the surgery, which did subside. Studies, UA and blood culture were negative. The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:, Transfer to ABC for rehab and continued care. Diabetic diet. Activity, ambulate as tolerated with posterior hip precautions. Rehab potential fair. He will need nursing, Social Work, PT/OT, and nutrition consults. Resume home meds, DVT prophylaxis, aspirin, and compression stockings. Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.discharge summary, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3650
}
|
PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:, This is a 42-year-old female. Refer to note in patient chart for documentation of history and physical. Due to the nature of the patient's increasing pain, surgery is recommended. The alternatives, risks and benefits of surgery were discussed with the patient. The patient verbalized understanding of the risks as well as the alternatives to surgery. The patient wished to proceed with operative intervention. A signed and witnessed informed consent was placed on the chart. Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:, Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1. There was a medium-sized (5 - 10 mm) anterior acromial spur.,2. The subacromial bursa was inflamed.,3. The subacromial bursa was thickened.,4. There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral. Muscles and Tendons: The biceps tendon is within normal limits.,JOINT:, Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table. All body parts were well padded and protected to make sure there were no pressure points. Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1. Scope Ports: Anterior Portal.,2. Scope Ports: Posterior Portal.,3. Scope Ports: Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1. The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2. The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3. The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4. The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr. Approximately 5 mm of bone was removed. The coracoacromial ligament was released with the bony resection. The shoulder joint was thoroughly irrigated.,5. The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6. The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures). The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7. The repair was stable to palpation with the probe and watertight.,8. The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:, The joint was thoroughly irrigated with 7 L of sterile saline. The portal sites were infiltrated with 1% Xylocaine. The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:, Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:, Final counts were correct.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3651
}
|
HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues. I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.soap / chart / progress notes, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These 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": 3652
}
|
PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:, Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED: ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS: ,50 mL.,NEEDLE AND SPONGE COUNT:, Correct.,SPECIMENS: , None.,TOURNIQUET TIME: ,Approximately 77 minutes.,IMPLANTS USED:,1. Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2. All-poly patella, size 32/8.5 mm thickness.,3. Prolong highly cross-linked polyethylene 12 mm.,4. Stemmed tibial component, size 2.,5. Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability. Surgery was indicated to relieve her pain and improve her functional ability. Goal objectives and the procedure were discussed with the patient. Risks and benefits were explained. No guarantees have been made or implied. Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE: ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion. A nonsterile tourniquet was placed proximally in the thigh. Antibiotics were infused prior to Foley catheter insertion. Time-out procedure was called.,A straight longitudinal anterior midline incision was made. Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia. Deep fascia was exposed. The tourniquet was inflated at 300 mmHg prior to the skin incision. A standard medial parapatellar approach was made. The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion. Incision was then carried down distally and distal arthrotomy was completed. Patellar tendon was well protected. Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair. The knee was exposed very well. Significant tricompartmental osteoarthritis was noted. The osteophytes were removed with a rongeur. Anterior and posterior cruciate ligaments were excised. Medial and lateral meniscectomies were performed. Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity. The medial compartment was more affected than lateral. Medial ligaments were tied. Retropatellar fat pad was excised. Osteophytes were removed. Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur. The trochlear notch was ossified. A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment. The anterior portal was 1 cm anterior to the PCL attachment. The anterior femoral sizer was positioned keeping 3 degrees of external rotation. Rotation was also verified using the transepicondylar axis and Whiteside line. The pins were positioned in the appropriate holes. Anterior femoral cut was performed after placing the cutting guide. Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned. A distal femoral cut was made which was satisfactory. A sizer was positioned which was noted to be D. The 5-in-1 cutting block size D was secured with spring pins over the resected bone. Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer. Then using a reciprocating saw, intercondylar base notch cut and side cuts were made. Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle. Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed. The bone with its attached soft tissue was removed. Once the femoral preparation was completed, attention was placed for the preparation of the tibia. The medial and the lateral collateral ligaments were well protected with a retractor. The PCL retractor was positioned and the tibia was translated anteriorly. Osteophytes were removed. The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle. Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe. Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest. A built-in 7-degree posterior slope was considered with instrumentation. Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site. Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane. The resected thickness of the bone was satisfactory taken 2 mm from the most affected site. The resected surface shows some sclerotic bone medially. Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle. Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed. Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion. Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension. The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia. Size 2 tibial trial plate was positioned. Appropriate external rotation was maintained with the help of the horseshoe alignment rod. Reference to the tibial crest distally and 2nd toe was considered as before. The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle. The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor. At this point, trial femoral and tibial components were reduced using a 12 mm trial liner. The range of motion and stability in both flexion and extension was satisfactory. No further soft tissue release was indicated. I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella. Using a patellar caliper, the thickness was measured to be 21.5 mm. This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact. Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide. Using a caliper, the resected patella was measured, which was noted to be 13 mm. A 32 sizer was noted to accommodate the resected surface very well. Drilling was completed and trial 32 button was inserted without any difficulty. The tracking was satisfactory. There was no evidence of any subluxation or dislocation of the patella. The trial components position was satisfactory. The alignment and the rotation of all 3 components were satisfactory. All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system. The resected surfaces were dried with a sponge. Two batches of Palacos cement were mixed. The cementing was initiated starting with tibia followed by femur and patella. Excess peripheral cement were removed with the curette and knife. The knee was positioned in extension with a 12 mm trial liner. Patellar clamp was placed after cementing the all-poly patella. Once the cement was set hard and cured, tourniquet was deflated. Hemostasis was achieved. The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner. Range of motion and stability was verified at 0 degrees and flexion of 120 degrees. Anterior-posterior drawer test was satisfactory. Medial and lateral stability was satisfactory. Patellar tracking was satisfactory. The wound was thoroughly irrigated. Hemostasis was achieved. A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine. The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion. The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally. The skin was approximated with staples. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient was then transferred to the recovery room in a stable condition. There were no intraoperative complications noted. She tolerated the procedure very well.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3653
}
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PREOPERATIVE DIAGNOSIS:, Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE: ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, 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 and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.ophthalmology, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3654
}
|
REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted. She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested. She had an echo done, which shows moderate pericardial effusion with early tamponade. The patient has underlying shortness of breath because of COPD, emphysema and chronic cough. However, denies any dizziness, syncope, presyncope, palpitation. Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien. She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY: ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:, Still smokes, but less than before. Drinks socially.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable not in any distress.,VITAL SIGNS: Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT: Atraumatic and normocephalic.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Breath sounds vesicular. Clear on auscultation.,HEART: PMI could not be localized. S2 and S2 regular. No S3, no S4. No murmur.,ABDOMEN: Soft and nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000. Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:, Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______. CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1. Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2. Lung cancer with metastasis most likely.,3. Pneumonia.,4. COPD.,PLAN: , We will get CT surgery consult for pericardial window. Continue present medication.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3655
}
|
VITAL SIGNS:, Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear.,NECK: ,Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes.,RESPIRATORY:, Lungs are clear to auscultation bilaterally. The patient has a normal respiratory rate, no signs of consolidation and no egophony. There are no retractions or secondary muscle use. Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:, Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal.,HEME/LYMPH: ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3656
}
|
PREOPERATIVE DIAGNOSIS:, Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:, General,NAME OF OPERATION:, Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:, The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and Veress needle placed without difficulty. Gas was entered into the abdomen at two liters. The laparoscope was entered, and the abdomen was visualized. The second puncture site was made, and the second trocar placed without difficulty. The cyst was noted on the left, a 3-cm, ovarian cyst. This was needled, and a hole cut in it with the scissors. Hemostasis was intact. Instruments were removed. The patient was awakened and taken to the recovery room in good condition.radiology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3657
}
|
REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation. Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS: ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:, Married, active smoker, does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above. The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of blurry vision and hearing impaired. No glaucoma.,CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior history of chest pain.,RESPIRATORY: Bronchitis and pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Non-significant.,NEUROLOGICAL: No TIA. No CVA or seizure disorder.,ENDOCRINE: Non-significant.,HEMATOLOGICAL: Non-significant.,PSYCHOLOGICAL: Anxiety. No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART: PMI displaced. S1 and S2, regular. Systolic murmur.,ABDOMEN: Soft and nontender.,EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect. Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7. INR 1.8. BUN and creatinine within normal limits. Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3658
}
|
NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized. A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic. A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome. A 5- to 5.5-mm anterior capsulorrhexis was created. The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag. The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique. Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification. Peripheral cortex was removed with the irrigation and aspiration handpiece. The posterior capsule was polished. The capsular bag was expanded with viscoelastic. The implant was inspected under the microscope and found to be free of defects. The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag. The trailing haptic was positioned with the cartridge system. Residual viscoelastic was removed from the anterior chamber and from behind the implant. The corneal wound was hydrated with balanced salt solution. The anterior chamber was fully re-formed through the side-port incision. The wound was inspected and found to be watertight. The intraocular pressure was adjusted as necessary. The lid speculum was removed. Topical Timoptic drops, Eserine and Dexacidin ointment were applied. The eye was shielded. The patient appeared to tolerate the procedure well and left the operating room in stable condition. Followup appointment is with Dr. X on the first postoperative day.surgery, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: 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": 3659
}
|
PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.gastroenterology, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3660
}
|
FEMALE REVIEW OF SYSTEMS:,Constitutional: Patient denies fevers, chills, sweats and weight changes.,Eyes: Patient denies any visual symptoms.,Ears, Nose, and Throat: No difficulties with hearing. No symptoms of rhinitis or sore throat.,Cardiovascular: Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,Respiratory: No dyspnea on exertion, no wheezing or cough.,GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU: No dysuria, frequency or incontinence. No difficulties with vaginal discharge.,Musculoskeletal: No myalgias or arthralgias.,Breasts: Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge.,Neurologic: No chronic headaches, no seizures. Patient denies numbness, tingling or weakness.,Psychiatric: Patient denies problems with mood disturbance. No problems with anxiety.,Endocrine: No excessive urination or excessive thirst.,Dermatologic: Patient denies any rashes or skin changes.general medicine, constitutional, breasts, cardiovascular, dermatologic, endocrine, female review of systems, musculoskeletal, neurologic, psychiatric, review of systems, respiratory, abdominal pain, chest pains, constipation, diarrhea, hematochezia, melena, nausea, nipple discharge, numbness, orthopnea, palpitations, paroxysmal nocturnal dyspnea, rashes, tingling, vomiting, weakness, wheezing, nose, systems,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3661
}
|
PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS: ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time.surgery, thyroid, rubber band drain, berry ligaments, papillary carcinoma, follicular variant, strap muscles, thyroid gland, sternocleidomastoid, parathyroid, hemithyroidectomy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3662
}
|
PROCEDURES PERFORMED:, Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:, Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.neurosurgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3663
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|
DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.nan
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{
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"id": 3664
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SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,
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{
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PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Rotated cuff tear, right shoulder.,2. Glenoid labrum tear.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic glenoid labrum debridement.,2. Subacromial decompression.,3. Rotator cuff repair, right shoulder.,SPECIFICATIONS:, Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital. This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention. He was completely refractory to conservative outpatient therapy. After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed. There was noted to be a degenerative glenoid labrum tear. The biceps complex was otherwise intact. There were minimal degenerative changes at the glenohumeral joint. Rotator cuff tear was appreciated on the inner surface. Subacromially, the same was true. This was an elliptical to V-type tear. The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department. He was safely placed in modified beach chair position. He was prepped and draped in the usual sterile manner. Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion. Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly. Debridement was carried out to the glenoid labrum. The biceps was probed and noted to be intact. Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed. The scope was placed subacromially and a lateral portal created. Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters. An anterolateral portal was created. Sutures were placed via express silk as well as other sutures with a #2 fiber wire. With passing of the suture, they were tied with a slip-tight knot and then two half stitches. There was excellent reduction of the tear. Superolateral portal was then created. A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone. _______ suture was placed. The implant was put into place. The loop was grabbed and it was impacted in the previously drilled holes. There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie. A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint. Gross bursectomy lightly was carried out to remove all bony elements. A pain buster catheter was placed through a separate portal and cut to length. 0.5% Marcaine was instilled after portals were closed with #4-0 nylon. Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing. The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition. Expected surgical prognosis of this patient is fair.surgery, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,
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{
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ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:, Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP: ,At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as notedorthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg
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{
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DIAGNOSIS:, Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended.neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE
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{
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HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN: ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.neurology, lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness,
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{
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CHIEF COMPLAINT:, Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient was transfused with 2 units of autologous blood postoperatively. She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings. The remainder of her postoperative course was uneventful. She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation. The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital. She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties. She reports having some right knee pain, which is most intense at a "certain position." The patient is unable to elaborate on which "certain position" causes her the most discomfort.,ALLERGIES:, NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:, On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL: No acute distress at the time of the exam except as mentioned above complains of right knee pain at "certain position.",HEENT: Normocephalic. Sclerae nonicteric. EOMI. Dentition in good repair. Tongue is in midline with no evidence of thrush.,NECK: No thyroid enlargement. Trachea is midline.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Soft, nontender, and nondistended. No organomegaly.,EXTREMITIES: The right knee incision is intact. Steri-Strips are in place. There is some diffuse right knee edema and some limited ecchymosis as well. No calf tenderness bilaterally. Pedal pulses are palpable bilaterally.,MENTAL STATUS: The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation. She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery. The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours. Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain. She remarked that she had a better degree of flexibility, but she did report an increased need for pain management. Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder. On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen. The patient reported that this rash was itchy. She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively. She was treated with betamethasone cream applied to the rash b.i.d. The patient's therapy had progressed and she continued to make a good progress. At one point, the patient reported some insomnia due to right knee pain. She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain. The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range. The Coumadin was adjusted accordingly according to the INRs during her hospital course. Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally. Initial laboratory data includes a UA on 08/28/2007, which was negative. Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000. Chemistries were within normal limits. Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102. The remainder of chemistries was unremarkable. The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1. Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2. Anxiety disorder.,3. Insomnia secondary to pain and anxiety postoperatively.,4. Postoperative constipation.,5. Contact dermatitis secondary to preoperative gardening activities.,6. Hypertension.,7. Hypothyroidism.,8. Gastroesophageal reflux disease.,9. Morton neuroma of the feet bilaterally.,10. Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications: Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily. The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926. At the present time, the patient is taking Coumadin 7 mg daily. She will remain on Coumadin for 30 days. An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary. Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office. The patient is encouraged to follow up with her primary care physician, Dr. B. As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.nan
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PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3. Right L4-S1 posterolateral fusion with local bone graft.,4. Left L4 through S1 segmental pedicle screw instrumentation.,5. Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:, Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots. The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed. General anesthesia was induced. The patient was intubated. Foley catheter was in place. The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. A previous incision was infiltrated with local and incised with a scalpel. The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala. Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting. The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed. Pars interarticularis were maintained. Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. Pedicle screws were placed L4-L5 and S1 on the right side. Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. It showed no penetration outside the pedicle vertebral body. At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed. Good bone purchase was obtained. Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1. Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. Prior to placement of BMP, the wound was irrigated with antibiotic irrigation. Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision. Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl. Skin was stapled. The drain was sutured in place with 2-0 Vicryl and connected to closed drain system. The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. The patient tolerated the procedure well without apparent complication. Final sponge and needle counts are correct. Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle
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CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.nan
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{
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PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED: ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region. This was completely excised.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:, None.,DRAINS:, None.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine in position under general anesthesia. First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated. The lesion in the tongue could be seen. Then, it was injected with 1% lidocaine and 1:100,00 epinephrine. After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total. Suction cautery was used for hemostasis. Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy,
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}
|
HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES: ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single. He is a student. He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies weight loss/gain, fever, chills.,ENMT: The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV: The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY: The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI: The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU: The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS: The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO: The patient had a loss of consciousness during the accident. He does not recall the details of the accident. Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH: Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY: Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. The patient shows moderate obesity.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click or rub. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 3+ bilaterally, without audible bruits. Extremities show no edema or varicosities.,GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.,LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL: Normal gait and station. The patient is on a stretcher. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN: There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. No induration or subcutaneous nodules to palpation.,NEUROLOGIC: Normal sensation by touch. The patient moves all four extremities.,PSYCHIATRIC: Oriented to time, place, and person. Appropriate mood and affect.,LABORATORY DATA: Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1. Concussion.,2. Facial abrasion.,3. Scalp laceration.,4. Knee abrasions.,PLANS/RECOMMENDATIONS:, Admitted for observation.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3674
}
|
PROCEDURE DONE: ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:, Chest pain.,PROCEDURE:, 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes. Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected. Resting heart rate was 90 beats per minute. Resting blood pressure was 130/70. Peak heart rate obtained during adenosine infusion was 102 beats per minute. Blood pressure obtained during adenosine infusion was 112/70. During adenosine infusion, patient experienced dizziness and shortness of breath. No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect. Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium. Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%. Lung heart ratio was 0.40. TID ratio was 0.88.,IMPRESSION:, Normal adenosine Myoview myocardial perfusion SPECT. Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.radiology, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3675
}
|
PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:, Left medial compartment osteoarthritis of the knee.,PROCEDURE PERFORMED:, Left unicompartmental knee replacement.,COMPONENTS USED:, Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:, None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side. She has done quite well with this. She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table. After appropriate anesthesia, the left lower extremity was identified with a time out procedure. Preoperative antibiotics were given. Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet. The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used. Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed. The anterior fat pad was removed. The knee was then examined. The ACL was found to be intact. The lateral compartment had very minimal arthritis. There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild. Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place. Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection. Following this resection, the femoral intramedullary guide was placed without difficulty. The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide. Once in the appropriate position, it was pinned and drilled. This was removed, and the posterior cutting block was inserted. It was impacted into place. Posterior bone cut was made for the medium femoral component. Next, a zero spigot was used and the distal femur was reamed. Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well. Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit. Next, the tibia was prepared. The tibial tray was pinned into place, and the cuts for the keel of the tibia were made. These were removed with a small osteotome from the set. Following this, a trial tibial with the keel was placed and it did fit nicely. After this, all trial components were removed. The knee was copiously irrigated. Cement was begun mixing. Drill holes were used along the femur for cement interdigitation. The wound was cleaned and dried. Cement was placed on the tibia. Tibial tray was impacted into place. Excess cement was removed. Tibia was placed in the femur. Femoral component was impacted into place. Excess cement was removed. It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened. Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size. A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion. The intramedullary rod removed from the femur. The wound was irrigated with normal saline. The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin. A sterile dressing was placed. Tourniquet was then desufflated. Sponge and needle counts were correct at the end of the procedure. Dr. Jinnah was present for the surgery. The patient was transferred to the recovery room in stable condition. She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis. Prior to closure, the posterior capsule was injected with the joint cocktail.orthopedic, knee replacement, osteoarthritis, osteoarthritis of the knee, excess cement was removed, medium femoral component, medial compartment osteoarthritis, unicompartmental knee replacement, medium femoral, femoral intramedullary, intramedullary guide, medial compartment, femoral component, tibial tray, lower extremity, unicompartmental knee, tibial, knee, tourniquet, intramedullary, extension, flexion, compartment, unicompartmental, replacement, femoral, cement,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3676
}
|
PREOPERATIVE DIAGNOSIS:, Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUID RECEIVED: ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:, The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:, Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring. Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis. The plan is for evaluation and repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. The patient was placed in supine position and examined. The left testis well within scrotum. The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped. An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage. We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl. We entered the peritoneum with the 5-mm one-step system. We then used the short 0-degree lens for laparoscopy. We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg. There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found. Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures. Then skin was closed with subcutaneous closure of 4-0 Rapide. A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery. Electrocautery was used for hemostasis. A curved tenotomy scissor was used to open the sac. The tunica vaginalis was visualized and grasped and then dissected up towards external ring. There was no apparent testicular tissue. We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent. We then closed the subdartos area with the subcutaneous closure of 4-0 chromic. We then did a similar curvilinear incision on the left side for testicular fixation. Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age. We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum. At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure. The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.urology, diagnostic laparoscopy, caudal block, testis fixation, undescended testis, subcutaneous closure, testis, orchiectomy, laparoscopy, testicular, scrotum
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3677
}
|
PREOPERATIVE DIAGNOSIS:, Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY: ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway. She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation. Endoscopic reevaluation of her tube and nature of the proposed procedure done. Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice. Cardiorespiratory anesthetic results were discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room and placed in the supine position. Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted. The patient was then prepared for endoscopy. The Kantor laryngoscope was then inserted. Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions. Larynx was then ***** short epiglottis. Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords. This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable. However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes. The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube. The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed. The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out. Mid and distal trachea were widely patent. Trachea and mainstem bronchi were patent without obvious disease. The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant. This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted. The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3678
}
|
PREOPERATIVE DIAGNOSES:,1. Eyebrow ptosis.,2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. Cervical facial aging with submental lipodystrophy.,OPERATION:,1. Hairline biplanar temporal browlift.,2. Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3. Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT: ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia. Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid. The lower limb of the fusiform ellipse was at the superior palpebral fold. A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim. This was performed bilaterally and symmetrically and the skin was removed. Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket. An incision was made over the superior orbital rim. Subperiosteal dissection was performed over the forehead. The dissection proceeded medially. The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion. A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm. A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid. The incision was made in the lower lid just beneath the lashline. Subcutaneous dissection was performed over the pretarsal and preseptal muscle. Dissection was then proceeded down to the inferior orbital rim. The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim. The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle. The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally. The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow. The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid. The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition. The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides. Closure was performed with interrupted 6-0 silk suture for the lower lid. The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy. Incisions were made in preauricular area, postauricular area, mastoid and occipital area. Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline. Submental lipectomy was performed through the incision in the submental crease. Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery. A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia. This was performed bilaterally and symmetrically. Hemostasis was achieved with electrocautery. The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed. The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture. Drains were placed prior to final closure. A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture. Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing. Scleral eye protectors were removed. Maxitrol eye ointment was placed followed by Swiss therapy eye pads. The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.ophthalmology, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3679
}
|
PREOPERATIVE DIAGNOSIS:, Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED: ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE: ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity. The mass has been increasing in size and symptoms according to the patient. The risks and benefits of the surgical excision were discussed. The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps. It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room. She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion. Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity. The skin and subcutaneous tissue were incised as well as the muscular fascia. The fibers of the biceps were divided bluntly and retracted. The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures. The mass was submitted to Pathology. Good hemostasis was seen. The wound was irrigated and closed in layers. The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture. Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion. The patient was given wound care instructions and will follow up again in my office in one week. Overall prognosis is good.surgery, excision, mass lesion, intramuscular, muscular fascia, vicryl suture, intramuscular lipoma, suture, mass, lipoma
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3680
}
|
PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:, Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion. Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid. A frontal nerve block was also given on the right upper lid. The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect. The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly. The specimen was then marked and sent to pathology for frozen section. Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid. The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis. Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly. It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region. The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures. The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied. The patient tolerated the procedure well and was sent to recovery room in good condition.ophthalmology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3681
}
|
OPERATIVE PROCEDURE:, Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:, Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina. Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings. The patient tolerated the procedure well. Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending. Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:, Pneumonia, infiltrates.cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3682
}
|
PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:, Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:, None.,CULTURES:, Intra-abdominally are done.,HISTORY: ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room. The pain has started in the umbilical area and radiated to McBurney's point. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix. The patient was seen by Dr. Y at my request in the ER with me in attendance. We went over the case. He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed. The patient on ultrasound had a 0.9 cm ovarian cyst on the right side. The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality. The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection. The patient has had hospitalization for this. The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery. All questions were answered. ,PROCEDURE: ,The patient was seen in the Emergency Room. In the Emergency Room, there is really no apparent vaginal discharge. No odor or cervical motion tenderness. Negative bladder sweep. Adnexa were without abnormalities. In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size. The patient had no adnexal fullness. The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope. We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus. The both fallopian tubes were seen. There did not appear to be hydrosalpinx. The ovaries were seen. The left showed some adhesions into the ovarian fossa. The cul-de-sac had a banded adhesions. The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged. The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap. The patient's bowel was otherwise unremarkable. The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID. The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right. The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left. The patient's case was turned over to him. Dr. Y was performed an appendectomy following which cultures and copious irrigation. Dr. Y was then closed the case. The patient was placed on antibiotics. We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1. Periappendicitis.,2. Pelvic inflammatory disease.,3. Chronic adhesive disease.obstetrics / gynecology, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3683
}
|
PAST MEDICAL HISTORY:, Significant for hypertension. The patient takes hydrochlorothiazide for this. She also suffers from high cholesterol and takes Crestor. She also has dry eyes and uses Restasis for this. She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout. She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993. She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash. The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker. She only drinks socially one to two drinks a month. She is employed as a manager at the New York department of taxation. She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure. She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes. She also complains about snoring and occasional slight asthma. She does complain about peripheral ankle swelling and heartburn. She also gives a history of hemorrhoids and bladder infections in the past. She has weight bearing joint pain as well as low back degenerating discs. She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION: ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20. Well nourished, well developed in no distress. Eye exam, pupils equal round and reactive to light. Extraocular motions intact. Neuro exam deep tendon reflexes 1+ in the lower extremities. No focal neuro deficits noted. Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit. Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished. Cardiac exam regular rate and rhythm without murmur or bruit. Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen. No palpable tenderness. No right upper quadrant tenderness. No organomegaly appreciated. No obvious hernias noted. Lower extremity exam +1 edema noted. Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities. The patient is interested in gastric bypass surgery. The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels. Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively. I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.bariatrics, weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3684
}
|
CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3685
}
|
HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity . , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. , ,MEDICATIONS: , Claritin for allergic rhinitis. , ,ALLERGIES: , None. , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft.general medicine, return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3686
}
|
PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day.gastroenterology
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3687
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REASON FOR CONSULT:, Depression.,HPI:, The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006. The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty. Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture. This was also treated with vertebroplasty. The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time. Her pain is in her upper back around her shoulder blades. The patient says lying down with the heated pad lessens the pain and that any physical activity increases it. MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading). Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason. Does not see any future for herself. Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore. Admits to decreased appetite, feeling depressed, and always wanting to be alone. Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace. Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity. Denies auditory and visual hallucinations. No paranoid, delusions, or other abnormalities of thought content. Denies panic attacks, flashbacks, and other feelings of anxiety. Does admit to feeling restless at times. Is concerned with her physical appearance while in the hospital, i.e., her hair looking "awful.",PAST MEDICAL HISTORY:, Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes. No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:, Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:, Unknown.,ALLERGIES:, CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:, Unremarkable.,PAST PSYCHIATRIC HISTORY:, Unremarkable. Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:, Unremarkable childhood. Married for 40 plus years, widowed in 1981. Worked as administrative assistant in UTMB Hospitals VP's office. Two children. Before admission, lived in the Terrace Independent Living Center. Was happy and very active while living there. Had friends in the Terrace and would not mind going back there after discharge. Occasional glass of wine at dinner. Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:, The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed. Slight decrease in motor activity. Normal eye contact. Speech, low volume and rate. Good articulation and inflexion. Normal concentration. Mood, labile, tearful at times, depressed, then euthymic. Affect, mood congruent, full range. Thought process, logical and goal directed. Thought content, no delusions, suicidal or homicidal ideations. Perception, no auditory or visual hallucinations. Sensorium, alert, and oriented x3. Memory, fair. Information and intelligence, average. Judgment and insight, fair.,MINI MENTAL STATUS EXAM,: A 28/30. Could not remember two out of the three recalled words.,ASSESSMENT:, The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures. The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I: Major depression disorder.,Axis II: Deferred.,Axis III: Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV: Lives independently at Terrace, difficulty walking, hospitalization.,Axis V: 45.,PLAN:, Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms. Discussed about possible inpatient psychiatric care.,Thank you for the consultation.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3688
}
|
PREOPERATIVE DIAGNOSIS:, Desire for sterility.,POSTOPERATIVE DIAGNOSIS:, Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped. Then, 1% lidocaine was used for anesthesia. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas. A segment about 3 cm in length was dissected out. It was clipped proximally and distally, and then the ends were cauterized after excising the segment. Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic. The identical procedure was performed on the contralateral side. He tolerated it well. He was discharged from the surgical center in good condition with Tylenol with Codeine for pain. He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead. Call if there are questions or problems prior to that time.urology, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3689
}
|
PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:, A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation. The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating. The following day he noted increasing pain and first noted blood on the surface of his stool. The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge. The patient denies any previous history of rectal bleeding or pain. He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative. The patient does state that he has not felt well for the past week. He states that he had felt "feverish" on several occasions but has not taken his temperature. He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue. He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13. He admits to eight previous partners and states that he "usually" uses a condom. On further questioning, the patient states that of his eight partners, three were female and five were male. His most recent sexual partner was a 38-year-old man whom he has been with for the past six months. He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing. He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy. The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family. As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life. He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men. He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT: Several areas of white plaque-like material on the buccal mucosa.,Neck: Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs: Clear to auscultation.,Cardiac: Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen: Soft without hepatosplenomegaly.,GU: Tanner V male with no external penile lesions.,Lymph: 2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal: Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12. 5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab: numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge. The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination. The following are in the differential diagnosis: Acute Proctitis and Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use. Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion. The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD. The patient could experience more systemic symptoms with fever and malaise, as found with this patient. However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS: ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae. An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult. First, the patient utilized the emergency department for care as opposed to identifying a primary care provider. Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed. Second, this young man has had both male and female sexual partners. As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors. Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions. Third, screening for STDs must take into account sexual behaviors. Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections. If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs. Fourth, this young man had both localized and systemic symptoms. As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation. In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered. The care provided to this young man included the following. He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis. Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae. At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program. The case manager linked this young man directly to care after providing brief counseling and support. The case manager maintained contact with the young man until his first clinical visit four days later. Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mLnan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3690
}
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PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS: ,None.,COMPLICATIONS:, None.,ANESTHESIA:, General.,SKIN PREPARATION: ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size. Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left. The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner. The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter. The ventricular catheter was then disconnected from the reservoir and endoscopically explored. We saw it was blocked up proximally. The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter. The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle. It irrigated out well. There was minimal amount of bleeding, but not significant. The distal catheter system was tested. There was good distal run off. Therefore, a linear skin incision was made in the retroauricular area. Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve. All connections were secured with 2-0 Ethibond sutures. Careful attention was made to make sure that the ProGAV was in the right orientation. The wounds were irrigated out with Bacitracin, 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. He was awakened, extubated and taken to recovery room in satisfactory condition.neurosurgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3691
}
|
HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2. Consider cardiology consult and further evaluation if clinically indicated.,3. Full report was sent to the PACS. Report will be mailed to Dr. ABC.radiology, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3692
}
|
PREOPERATIVE DIAGNOSES:,1. Ischemic cardiomyopathy.,2. Status post redo coronary artery bypass.,3. Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1. Ischemic cardiomyopathy.,2. Status post redo coronary artery bypass.,3. Status post insertion of intraaortic balloon.,4. Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1. Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2. Open sternotomy covered with Ioban.,3. Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field. A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass. A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle. The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava. A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava. After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium. After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place. A cardiectomy was then performed by starting in the right atrium. The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field. Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed. The right and left atrium, aorta, and pulmonary artery were prepared for the transplant. First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture. The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene. The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood. Air was evacuated and the sutures were tied down. The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass. The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass. Blood factors and factor VII were given to try and correct the coagulopathy. Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture. Hemofiltration was started in the operating room at this time. After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound. The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively. This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy. The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII. Urine output for the procedure was 520 mL. The preservation time of the heart is in the anesthesia sheet. The estimated blood loss was at least 6 L. The patient was taken to the intensive care unit in guarded condition.cardiovascular / pulmonary, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3693
}
|
HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare. This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon. Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy. On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon. He has been followed conservatively since that time. A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg. Right coronary artery to pulmonary artery fistula was also appreciated. The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:, The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case. 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 7-French sheath, a 6-French wedge catheter was inserted. The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries. This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,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 recovery room in satisfactory condition. There were no complications.,DISCUSSION:, Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with no evidence of intracardiac shunt. Left-sided heart was fully saturated. Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Right ventricular systolic pressure was mildly elevated at 45% systemic level. There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries. Phasic branch pulmonary artery pressures were normal. Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency. The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation. There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus. The pulmonary valve appeared to be thin and moved well. The median branch pulmonary arteries were of good size with normal distal arborization. Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1. Membranous pulmonary atresia.,2. Atrial septal defect.,3. Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS): ,1. Pulmonary valvotomy surgical.,2. Aortopulmonary artery central shunt.,3. Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES: ,1. Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2. Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3. Small right coronary artery to main pulmonary fistula.,4. Static encephalopathy.,5. Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference. Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated. Conservative outpatient management is to be recommended. Further patient care will be directed by Dr. X.cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3694
}
|
Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid. ,PLAN: ,Planned for electronystagmography to document the degree of vestibular hypofunction.,consult - history and phy., electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3695
}
|
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.dentistry, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3696
}
|
OPERATIVE PROCEDURE,1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:, The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.,The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.surgery, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3697
}
|
HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.consult - history and phy., hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3698
}
|
HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss. At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:, Significant for hypertension, for which the patient takes Norvasc and Lopressor for. She also suffers from high cholesterol and is on lovastatin for this. She has depression, for which she takes citalopram. She also stated that she had a DVT in the past prior to her hysterectomy. She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones. She also had a hysterectomy in 1994 secondary to hemorrhage. The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker. She is married, with 2 children aged 22 and 28. She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY: ,Significant for high blood pressure and diabetes as well as cancer on her father side. He did pass away from congestive heart failure. Mother suffers from high blood pressure, cancer, and diabetes. Her mother has passed away secondary to cancer. She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling. The patient also wears glasses for vision and has dentures. She does complain of shortness of breath with exertion. She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease. She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION: ,The patient is a well-nourished, well-developed female, in no distress. Eye Exam: Pupils equal and reactive to light. Extraocular motions are intact. Neck Exam: No cervical lymphadenopathy. Midline trachea. No carotid bruits. Nonpalpable thyroid. Neuro Exam: Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. Lung Exam: Clear breath sounds without rhonchi or wheezes. Cardiac Exam: Regular rate and rhythm without murmur or bruits. Abdominal Exam: Positive bowel sounds. Soft, nontender, obese, and nondistended abdomen. Lap cholecystectomy scars noted. No obvious hernias. No organomegaly appreciated. Lower extremity Exam: Edema 1+. Dorsalis pedis pulses 2+.,ASSESSMENT: ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy. Also the patient will meet with the dietitian and psychologist as per her usual routine. I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.bariatrics, jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3699
}
|
HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day. He has no significant blurriness of vision or photophobia.nan
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