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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3900
}
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PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name: Sigma.,Model #: SDR203.,Serial #: 123456.,ATRIAL LEAD,Model #: 4568-45 cm.,Serial #: 123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #: 4068-52 cm.,Serial #: 123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.,Again, thank you for allowing to participate in this care.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3901
}
|
PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, withsurgery, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3902
}
|
PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.neurosurgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3903
}
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PROBLEM LIST:,1. Refractory hypertension, much improved.,2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3. History of GI bleed in 1995.,4. History of depression.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for this patient. She is an 85-year-old woman with history as noted above. Her last visit was approximately four months ago. Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. She is not reporting any untoward side effect. She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. She has no orthopnea. Her exercise capacity is about the same. The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. No history of extremity pain.,CURRENT MEDICATIONS:,1. Triamterene/hydrochlorothiazide 37.5/25 mg.,2. Norvasc 10 mg daily.,3. Atenolol 50 mg a day.,4. Atacand 32 mg a day.,5. Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. THORAX: Revealed lungs that are clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3. I could not hear murmur today. ABDOMEN: Above plane, but nontender. EXTREMITIES: Revealed no edema.,ASSESSMENT:, This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. In the meantime, we will discharge her from our practice. Should there be confusion or difficulty getting in the senior center, we can always see her back in followupsoap / chart / progress notes, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3904
}
|
PROCEDURE PERFORMED:, Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. Alternatives were explained. They agreed to proceed with the lumbar puncture. Permit was signed and is on the chart. The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion. Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:, None. The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.orthopedic, spinal needle, lumbar puncture, lumbar, gauge, csf
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3905
}
|
CHIEF COMPLAINT:, Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms. Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis. He has had severe global developmental delay, and is nonverbal. He can follow objects with his eyes, but has no ability to interact with his environment to any great degree. He has noted if any purposeful use of the hands. He has abnormal movements constantly, which are more choreiform and dystonic. He has spastic quadriparesis, which is variable at times. The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms. I began seeing him at 20 months of age. At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms. The patient had benefit from this medication, and was doing well at that time with regard to that seizure type. He initially was on phenobarbital, which failed to give him benefit. He continued on phenobarbital; however, for a long period time thereafter. The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly. Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2. Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense. It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day. These events manifest as tonic spells with eye deviation and posturing. Mother reports flexion of the upper extremities, extension with lower extremities. During that time, he is not able to cry or say any sounds. These events last from seconds to minutes, and occur at least multiple times per week. There are times where he has none for a few days and other times where he has multiple days in a row with events. He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout. He may vomit after these episodes, then seems to calm down. It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:, The patient's medications include Lamictal for a total of 200 mg twice a day. It is a 150 mg tablet and 25 mg tablets. He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day. He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias. No respiratory or cardiovascular complaints. He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: The patient is a slender male who is microcephalic. He has EEG electrodes in place and is on the video EEG at that time.,HEENT: His oropharynx shows no lesions.,NECK: Supple without adenopathy.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs.,ABDOMEN: Benign with G-tube in place.,EXTREMITIES: Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL: The patient is alert and has bilateral esotropia. He is able to fix and follow objects briefly. He is unable to reach for objects. He exhibits constant choreiform movements when excited. These are more prominent in the upper extremities and lower extremities. He has some dystonic posture with flexion of the wrist and fingers bilaterally. He also has plantar flexion at the ankles bilaterally. His cranial nerves reveal that his pupils are equal, round, and reactive to light. Extraocular movements are intact other than bilateral esotropia. His face moves symmetrically. Palate elevates in midline. Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above. He has clonus at the ankles bilaterally, and some valgus contracture of the ankles. His sensation is intact to light touch bilaterally. Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy. He has microcephaly as well as dystonic cerebral palsy. He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort. He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types. He will remain hospitalized for probably at least 48 hours to 72 hours. He could be discharged sooner if multiple events are captured. His medications, we will continue his current dose of Zonegran and Lamictal for now. Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.consult - history and phy., brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3906
}
|
CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:, T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3907
}
|
PREOPERATIVE DIAGNOSES:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,5. Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:, 500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS: ,Normal appearing uterus, tubes, and ovaries. A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively. Infant weight equaled to 4140 gm with clear amniotic fluid. The umbilical cord was wrapped around the leg tightly x1. Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE: ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy. She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery. The patient had a positive group beta strep colonization culture and was started on penicillin. The patient was also started on Pitocin protocol at that time. The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor. IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units. The patient was given a rest from the Pitocin. She walked and had a short shower. The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions. Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position. At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound. Options were discussed with the patient and family and it was determined that we will take her for C-section today. Consent was signed. All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed. She was placed in the dorsal supine position with left upward tilt. She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate. A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel. The fascia was incised in the midline and extended laterally using curved Mayo scissors. The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles. Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle. The rectus muscle was separated in the midline bluntly. The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors. The peritoneum was then bluntly stretched. The bladder blade was placed. The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors. The incision was extended laterally and the bladder flap created digitally. The bladder blade was then reinserted in the lower uterine segment. A low transverse uterine incision was made with a second scalpel. The uterine incision was extended laterally bluntly. The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum. Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically. There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut. Infant was handed to the waiting pediatrician. Cord gas was sent for pH as well as blood typing. The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris. The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion. A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis. The uterus was returned to the abdomen. The gutters were cleared of all clots and debris. The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion. The fascia was reapproximated with #0-Vicryl suture in a running fashion. The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut. The skin was then closed with staples. The incision was dressed with sterile dressing and bandage. Blood clots were evacuated from the vagina. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The mother was taken to the recovery room in stable and satisfactory condition.obstetrics / gynecology, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3908
}
|
PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Enterolysis.,4. Lysis of the pelvic adhesions.,5. Left salpingo-oophorectomy.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:, None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions. Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 12 cm. The cervix was then serially dilated with Hank dilators to a size #20 Hank. Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum and weighted speculum were removed. Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision. Small amount of normal saline was injected into Veress needle and seemed to drop freely. So, the Veress needle was connected to he CO2 gas, which was started at the lower setting. It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. The abdomen was then insufflated to an adequate distention. Next, the Veress needle was removed and a size #11 step trocar was inserted. Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas. At this point, the initial operative findings were seen. Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization. A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. These were used to see the above operative findings. Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. Care was taken at all times to avoid the bowel and the ureters. The fallopian tubes appeared massively scarred and completely obliterated from disease. After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel. At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. Next, the needle was removed and the ligature device was inserted. This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. Then, the attention was turned to the inferior aspect of the ovary. First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. This was grasped with a clamp. The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port. The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant. Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. At this point, the remaining two size #5 ports were removed under direct visualization. The camera was removed and the abdomen was desufflated. Next, an introducer was replaced on a #11 port. The #11 port was removed. Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle. Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 3909
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INFORMANT:, Dad on phone. Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY: ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis. All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done. The patient was put on ampicillin and cefotaxime. Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime. The patient was n.p.o. when he came in. He was on 3/4 L of oxygen. According to the note, it conveyed that he had some subcostal retractions. On arriving here, baby looks very healthy. He has no subcostal retractions. He is not requiring any oxygen and he is positive for urine and stool. The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile. ED called that case is a direct admit.,REVIEW OF SYSTEMS: ,The patient supposedly had fever, some weight loss, poor appetite. The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria. According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color. He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low. Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:, None.,HOSPITALIZATIONS:, Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY: ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications. Hospital stay 24 hours. Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:, None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: ,Lives with mom and dad. Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog. They usually visit to a ranch, but not recently. No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:, No allergies.,DIET:, Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS: Weight 3.725 kg.,GENERAL: Alert and comfortable and sleeping.,SKIN: No rash.,HEENT: Intact extraocular movements. PERRLA. No nasal discharge. No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK: Soft, nontender, supple.,CHEST: CTAP.,GI: Bowel sounds present. Nontender, nondistended.,GU: Bilaterally descended testes.,BACK: Straight.,NEUROLOGIC: Nonfocal.,EXTREMITIES: No edema. Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:, As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000. Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5. Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4. Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal. UA and LP results are pending. Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative. We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime. The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis. These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient. He does not need any further workup.,GASTROINTESTINAL: nan
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"dataset_name": "medical-transcription-40",
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ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.urology, discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES: ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES: ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days.cardiovascular / pulmonary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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PREOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,OPERATIVE PROCEDURE:,1. Placement of a Port-A-Cath.,2. Fluoroscopic guidance.,ANESTHESIA:, General LMA.,ESTIMATED BLOOD LOSS:, Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy. Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed. The patient was taken to the operating room, placed in supine position. General LMA anesthesia was administered. She is prepped and draped in the usual sterile fashion. She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire. Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava. The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery. A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements. The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer. Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch. Heparin flush was used to flush the port. Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition. All counts were reported as correct and I was present for the entire procedure.surgery, anal cancer, fluoroscopic, fluoroscopy, iv access, port-a-cath, trendelenburg position, chemotherapy, subclavian vein, port a cath, subcutaneous tissues, insertion, subclavian
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3913
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SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.,HEART: Regular rhythm and rate.,ABDOMEN: Soft, less tender.,LABORATORY DATA:, Her white count continues to come down. Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000. We have ordered type and cross for 2 units of packed red blood cells. If it drops below 25, she will receive a transfusion. Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:, She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.soap / chart / progress notes, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3914
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HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X.soap / chart / progress notes, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3915
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PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descending, rectosigmoid and rectum. Retroflexion noted no abnormality of the internal ring. No hemorrhoids were noted. Withdrawal from the patient terminated the procedure.gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: 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": 3916
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|
PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2. Bone grafts.,3. Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:, None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis. We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft. We have discussed risks and benefits. Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection. The parents understand, decide to proceed with surgery. Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position. General anesthetic was administered. Prophylactic dose of antibiotic was given. Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees. The patient was once more positioned and padded in the usual manner. The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane. The subgaleal plane was developed and reflected anteriorly and slightly posteriorly. Hemostasis achieved with electrocautery. Raney clips were applied to both flaps to prevent significant bleeding. Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure. I assisted her and this will be described in a different operative report. Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor. The osteotomies were done with the Midas and some irrigation. There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim. This was done on both sides. Hemostasis achieved with bone wax and electrocautery. Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements. On the left side, there was a minor fracture to the superior orbital rim that was plated. The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim. The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches. The forehead flaps were attached with the help of absorbable mesh. The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws. Hemostasis was checked. The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut. Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net. The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition. I was present and participated in all aspects of the procedure. Sponge, needle, and instrument counts were completed at the end of the procedure.surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead,
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{
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"dataset_name": "medical-transcription-40",
"id": 3917
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PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1. Laparoscopic cholecystectomy.,2. Intraoperative cholangiogram.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted. Saline test was performed. Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg. The Veress needle was removed. A 10- to 11-mm cannula was inserted. Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it. It was largely mobile. The liver had a normal appearance as did the peritoneal cavity. A 5-mm cannula was inserted in the right upper quadrant anterior axillary line. A second 5-mm cannula was inserted in the subcostal space. A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction. The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal. Extra contrast was aspirated and the aspirating needle was removed. The ampulla was grasped with a second grasper, opening the triangle of Calot. The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided. This was done while the common duct was in full visualization. The cystic artery was similarly controlled and divided. The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution. There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula. The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear. Hemostasis was excellent. CO2 was evacuated and the camera removed. The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon. Sterile dressings were applied. Sponge and needle counts were correct.gastroenterology, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,
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{
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"dataset_name": "medical-transcription-40",
"id": 3918
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Sample Address,RE: Sample Patient,Wife's name: Sample Name,Dear Sample Doctor:,Mr. Sample Patient was seen on Month DD, YYYY, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan. He has remained azoospermic postoperatively. The operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal.,He states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife. Apparently, several attempts at induction have been tried and due to some anatomic abnormality, they have been unsuccessful.,At the time that he left the office, he was asking for cryopreservation. At the time of sperm harvesting, I recently received a phone call suggesting that he does not want to do this at all unless his wife's ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest. I look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately. At his initial request, Month DD, YYYY was picked as the date for scheduled harvesting, although this may change if you require fresh specimen.,Thank you very much for the opportunity to have seen him.,Sample Doctor, M.D.urology, letter, urology letter, azoospermic, cryopreservation, specimen harvest, sperm harvesting, vasectomy, vasectomy reversal, fresh specimen, reversal, sperm,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3919
}
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PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS: ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy. ,INDICATIONS: ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy. He has had previous colonoscopy. There is no family history of bleeding, no current problems with his bowels. On examination, he has internal hemorrhoids. His prostate is enlarged and increased somewhat in firmness. He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm. These were removed with snare polypectomy technique. I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation. Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%. A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve. The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port. The scope was withdrawn into the left transverse colon, where the second polyp was identified. It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well. The scope was then gradually withdrawn the remaining distance and removed. The patient tolerated the procedure well.gastroenterology, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3920
}
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CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation. The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure. She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose. She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL: This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT: External auditory canals are clear. Tympanic membrane shows no perforation, is intact.,NOSE: The patient has a slightly deviated right septum. Septum has a large perforation in the anterior 2/3rd of the septum. This appears to be well healed. There is no sign of crusting in the nose.,ORAL CAVITY: No lesions or sores. Tonsils show no exudate or erythema.,NECK: No cervical lymphadenopathy.,VITAL SIGNS: Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN: ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis. At this time, I counseled the patient on the risks and benefits of surgery. She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip. We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.ent - otolaryngology, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3921
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|
HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X. This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:, She was admitted. She was 3 cm dilated on admission. She desired induction of labor. Therefore, Pitocin was started. Epidural was placed for labor pain. She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy. She remained febrile, approximately 100.3. She then progressed. On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated. She had reported previously some mucous discharge with no ruptured membranes. Upon my exam, no membranes were noted. Attempted artificial rupture of membranes was performed. No fluid noted and there was no fluid discharge noted all the way until the time of delivery. Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor. She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:, Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise. Placenta delivery spontaneous. Condition was intact with a three-vessel cord. Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration. These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively. Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal. Apgars were 0 and 0. Weight pending at this time.,NARRATIVE OF DELIVERY:, I was called. This patient was completely dilated. I arrived. She pushed for three contractions. She was very comfortable. She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant. There was a tight nuchal cord x1 that was reduced after delivery of the fetus. Cord was doubly clamped. The infant was transferred to a bassinet cleaned by the nursing staff en route. The placenta delivered spontaneously, was carefully examined, found to be intact. No signs of abruption. No signs of abnormal placentation or abnormal cord insertion. The cord was examined and a three-vessel cord was confirmed. At this time, IV Pitocin and bimanual massage. Fundus firm as above with minimal postpartum bleeding. The vagina and perineum were carefully inspected. A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture. At this time, the repair is intact. She is hemostatic. All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time. We have called pastor in to baptize the baby as well as calling social work. They are deciding on a burial versus cremation, have decided against autopsy at this time. She will be transferred to postpartum for her recovery. She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise. I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.obstetrics / gynecology, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3922
}
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PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis. She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table. The abdomen was prepared and draped in usual sterile fashion. After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made. A Veress needle was inserted. Abdomen was insufflated to 15 mmHg. A 5-mm port and camera placed. The abdomen was visually explored. There were no obvious abnormalities. A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two. Blunt dissection was used to isolate the appendix. Appendix was separated from surrounding structures. A window was created between the appendix and the mesoappendix. GIA stapler was tossed across it and fired. Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler. Appendix was placed in an Endobag and removed from the patient. Right lower quadrant was copiously irrigated. All irrigation fluids were removed. Hemostasis was verified. The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device. All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures. Steri-Strips and sterile dressings were applied. Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3923
}
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DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE: ,The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself.general medicine, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3924
}
|
PREOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,OPERATIONS PERFORMED:,1. Bilateral carotid cerebral angiogram.,2. Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized. The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted. Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized. The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present. The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance. A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed. Heparin had been initially given, which was reversed with protamine. Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.surgery, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3925
}
|
S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet.,podiatry, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3926
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PREOPERATIVE DIAGNOSIS:, Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA: ,General oral endotracheal intubation.,PROCEDURE:, After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps. A bladed 11-mm port was inserted without difficulty. Pneumoperitoneum was obtained using C02. Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant. There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel. The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve. This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice. The appendix was somewhat retrocecal in position but otherwise looked normal. The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye. There was enough however in the wall to identify the location of the polyp. The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table. The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear. I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon. This new staple line was then opened on the back table and examined. There was some residual polypoid material noted but the margins this time appeared to be clear. The peritoneal cavity was then lavaged with antibiotic solution. There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery. The trocars were removed under direct vision. No bleeding was noted. The bladed trocar site was closed using a figure-of-eight O Vicryl suture. All skin incisions were closed with running 4-0 Monocryl subcuticular sutures. Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing. The patient tolerated the procedure well without any complications.surgery, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3927
}
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PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3928
}
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REASON FOR NEUROLOGICAL CONSULTATION:, Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001. He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands. More recently, he describes a burning sensation along with numbness. This has become a particular problem and of all the problems he has he feels that pain is his primary concern. Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands. He denies any weakness per se, just clumsiness and decreased sensation. He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders. This has been a fairly longstanding problem, and again has become more prevalent recently. He does not have any tremor. He denies any neck pain. He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control. Oxycodone helps somewhat and gives him at least three hours pain relief. Because of the pain, he has significant problems with fractured sleep. He states he has not had a good night's sleep in many years. About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility. At that facility, his insulin was stopped. Since then he has only been on oral medication for his diabetes. He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart. He does not smoke. He lives in a senior citizens building with daily nursing aids. He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds. Pain scale 7/10. A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination. Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip. Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion. Tone and bulk are normal. Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally. He has no vibration sense at his knees. Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally. The only reflexes I could obtain with trace reflexes in his biceps. Remaining reflexes were unelicitable. No Babinski. The patient walks normally with the aid of a cane. He has severe sensory ataxia with inability to walk unaided. Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1. Probable painful diabetic neuropathy. Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities. He has relative preservation of motor function. Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2. He has history of myoclonic jerks. I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy. I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1. EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2. Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3. Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d. Side effect profile of this medication was discussed with the patient.,4. I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5. I will see him at followup at the EMG.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3929
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TITLE OF OPERATION:, Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:, 900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid. No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:, After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. No active bleeding was noted. No evidence of ectopic pregnancy was noted. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The sponge on a sponge stick was removed from the vagina. The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.obstetrics / gynecology, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3930
}
|
HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED: ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver. No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION: ,1. Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2. Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3. Hypercholesterolemia.,4. History of anxiety.,5. History of coronary artery disease.,6. Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X. Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation. I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.ent - otolaryngology, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3931
}
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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.,gastroenterology, 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": 3932
}
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PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with Betadine. The patient was given sedation and monitored. Under fluoroscopy, the right sacral alar notch was identified. After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained. Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected. Coagulation was then carried out at 90oC for 90 seconds. The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint. Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications. The patient was returned to outpatient recovery in stable condition.surgery, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3933
}
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PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids. The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS: ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL:, A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure. The opportunity for questions was provided, and informed consent was obtained. Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position. Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus. We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose. Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum. We noticed that the patient had several ulcers in the first portion of the duodenum. Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there. Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest. By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose. Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken. At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth. The patient tolerated the procedure well with no complications.,FINAL IMPRESSION: ,1. Duodenal ulcers.,2. Loose lower esophageal sphincter.,PLAN:,1. To start omeprazole 20 mg a day.,2. To review the biopsies.,3. To return the patient back to clinic in 1 to 2 weeks.gastroenterology, esophagogastroduodenoscopy, esophageal, biopsies, endoscope
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3934
}
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A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve. This was done without difficulty and the bowel preparation was good. The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal. The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,COMPLICATIONS: , None.gastroenterology, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: 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": 3935
}
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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.pain management, 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": 3936
}
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IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3937
}
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PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot. The patient has a history of gradual onset of a painful bunion over the past several years. She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion. The foot was elevated off the table. Esmarch bandages were used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and the sterile stockinet was reflected. A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate. Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion. A #10 blade was used to make a 4 cm dorsolinear incision. A #15 blade was used to deepen the incision through the subcutaneous layer. All superficial subcutaneous vessels were ligated with electrocautery. Next, a linear capsular incision was made down the bone with a #15 blade. The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound. A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head. The medial plantar aspect of the metatarsal head had some erosive changes and eburnation. Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it. A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion. Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head. Nice correction was achieved and excellent bone to bone contact was achieved. The bone stock was slightly decreased, but adequate. Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment. A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique. Excellent rigid fixation was achieved. A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head. Again, an excellent rigid fixation was obtained and the screws were tight. The temporary fixation was removed. A medial overhanging bone was resected with a sagittal saw. The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge. A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy. A #15 drill blade was used to drill two converging holes on the medial aspect of the bone. A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone. The monofilament wire was twisted down and tapped into the distal drill hole. The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved. Next, reciprocating rasps were used to smooth all bony surfaces. Copious amounts of sterile saline was used to flush the joint. Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer. Next, #4-0 Vicryl was used to close the subcutaneous layer. #5-0 Vicryl was used to the close the subcuticular layer in a running fashion. Next, 1 cc of dexamethasone phosphate was then instilled in the joint. The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She is to be partial weightbearing with crutches. She is to follow with Dr. X. She was given emergency contact numbers and instructions to call if problems arise. She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d. 500 mg. She was discharged in stable condition.podiatry, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3938
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TITLE OF OPERATION:, Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: , The patient is a patient well known to my service. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life. I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes. I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1. We went to the operating room at that time and we did a very large right-sided hemicraniectomy. The patient was put in the intensive care unit. We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago. Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk. We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift. At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________ this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room. She was already intubated and under general anesthesia. The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder. The patient tolerated this well. We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin. We connected this. Prior to this, we brought in all surgical instrumentation under sterile and standard conditions. We opened the skin as in opening a book and then we also did a myocutaneous flap. We brought in the muscle with it. We had a very good exposure of the skull. We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly. We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side. At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly. All this was irrigated thoroughly. Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely. We had absolutely good hemostasis. We put a piece of Gelfoam over the brain. We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position. I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place. This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely. Once we had done this, irrigated thoroughly once again the skin. We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit. The EBL was about 200 cubic centimeters. Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct. No complications. The patient went back to the intensive care unit.surgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3939
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CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam., ,REVIEW OF SYSTEMS: ,The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative., ,PAST MEDICAL HISTORY: ,Significant for degenerative disc disease in the back., ,MEDICATIONS: ,Nexium., ,ALLERGIES:, IV contrast., ,CURRENT WORK STATUS:, He continues on full duty work., ,PHYSICAL EXAMINATION:, The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia., ,ASSESSMENT: ,The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above., ,IMPRESSION:, Blood-borne pathogen exposure secondary to contaminated needlestick., ,PLAN: ,The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts., ,WORK STATUS:, He was released to regular work., ,CONDITION: ,He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3940
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PREOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Negligible.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines. In the preoperative area, the patient received pilocarpine drops. The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain. Approximately 3 mL were given. The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye. During the draping process, care was taken to isolate the lashes. A screw type speculum was inserted to maintain patency of lids. A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade. This was approximately one-half scleral depth in thickness. A crescent blade was then used to dissect forward the clear cornea. Hemostasis was again achieved with wet-field cautery. A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. The site was then profusely irrigated with balanced salt solution. A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed. Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps. The iris was then repositioned into the eye and the anterior chamber was inflated with BSS. The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle. BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. Antibiotic and steroid drops were placed in the eye as was homatropine 5%. The antibiotic consisted of Vigamox and the steroid was Econopred Plus. A patch and shield were placed over the eye after the drape was removed. The patient was taken to the recovery room in good condition. She will be seen in followup in the office tomorrow.surgery, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3941
}
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PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:, Left undescended testis plus left inguinal hernia.,PROCEDURES:, Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:, A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:, Sponge and needle counts were correct x2.,SPECIMENS,: No tissues sent to Pathology.,ANESTHESIA:, General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left. 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, he was then placed in a supine position, and sterilely prepped and draped. A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue. We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring. We were able to dissect all the way up to the ring, but were unable to get the testis delivered. We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia. The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors. The testis itself was quite high up in the upper canal. We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors. Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture. We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length. We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off. We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum. The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch. The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture. The testis was then placed into the scrotum in the proper orientation. We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well. We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure. The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure. Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure. The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.urology, inguinal hernia repair, ilioinguinal nerve block, external oblique fascia, hernia repair, epididymal attachment, external ring, inguinal incision, scarpa fascia, cord length, inguinal hernia, nerve block, ilioinguinal nerve, undescended testis, testis, inguinal, fascia, hernia, dissected,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3942
}
|
A 1 cm infraumbilical skin incision was made. Through this a Veress needle was inserted into the abdominal cavity. The abdomen was filled with approximately 2 liters of CO2 gas. The Veress needle was withdrawn. A trocar sleeve was placed through the incision into the abdominal cavity. The trocar was withdrawn and replaced with the laparoscope. A 1 cm suprapubic skin incision was made. Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope. The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis. Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal. The probe was withdrawn and replaced with the bipolar cautery instrument. The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus. Electrical current was applied to the tube at this point and fulgurated. The tube was then regrasped just distal to this and refulgurated. It was then regrasped just distal to the lateral point and refulgurated again. The same procedure was then carried out on the opposite tube. The bipolar cautery instrument was withdrawn and replaced with the probe. The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes. The upper abdomen was visualized, and the liver surface was normal. The gas was allowed to escape from the abdomen, and the instruments were removed. The skin incisions were repaired. The instruments were removed from the vagina.,There were no complications to the procedure. Blood loss was minimal. The patient went to the postanesthesia recovery room in stable condition.obstetrics / gynecology, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubesNOTE,: 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": 3943
}
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PHYSICAL EXAMINATION,GENERAL: ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS: ,The ear canals are patent without edema, exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge. No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard.,NECK: , No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline.,CHEST: , Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally. No rales, rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm. No murmur. No S3, S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge. Vaginal vault is without discharge. Cervix is of normal color without lesion. The os is closed. There is no bleeding noted. Uterus is noted to be of normal size and nontender. No cervical motion tenderness is seen. No masses are palpated. The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted.,SKIN: , No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen.,PSYCHIATRIC: ,The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3944
}
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CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. She has normal bowel and bladder habits. No melena or hematochezia.,CURRENT MEDICATIONS: ,Macrobid 100 mg q.d.,ALLERGIES: ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. She is status post a left partial nephrectomy as a new born.,2. In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY: ,Her mother had uterine cancer. Her father had liver cancer.,PHYSICAL EXAM:,VIT:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3945
}
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EXAM:, Single frontal view of the chest.,HISTORY:, Respiratory distress. The patient has a history of malrotation. The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:, Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:, A single frontal view of the chest was evaluated. It reveals interval placement of an ET tube and an NG tube. ET tube is midway between the patient's thoracic inlet and carina. NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm. There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions. The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique. There is a slight increase seen with regards to the central pulmonary vessels. Again, this may represent a minimal amount of pulmonary vascular congestion. There is paucity of bowel gas seen in the upper abdomen. The osseous thorax appears to be grossly intact and symmetrical. Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1. No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2. Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3. Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.radiology, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3946
}
|
CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3947
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XYZ, D.C.,Re: ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side. The patient sustained impact injuries to his neck and lower back. There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures. He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg. He has had no difficulty with bowel or bladder function. He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:, He was injured in a prior motor vehicle accident on MM/DD/YYYY. At the time of his most recent injuries, he was completely symptom free and under no active therapy. There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS: ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:, Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level. MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function. Vital Signs: Blood pressure was 105/68 in the left arm sitting. Heart rate was 70 and regular. Height was 5 feet 8 inches. Weight was 182 pounds. Cranial nerve evaluation was unremarkable. Pupils were equal and reactive. Funduscopic evaluation was clear. There was no evidence for nystagmus. There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature. Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ symmetrical and active. No pathological responses were noted. Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity. Cerebellar function was normal. There was normal station and gait. Chest and cardiovascular evaluations were unremarkable. Heart sounds were normal. There were no extra sounds or murmurs. Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY. In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms. Palpable trigger points were noted on today's evaluation. He is suffering from ongoing myofascitis. His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time. I have encouraged him to continue with his ongoing treatment program under your care and supervision. I will be following him in two weeks' time. Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,orthopedic, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3948
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PREOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1. Left midface elevation with nasolabial fold elevation.,2. Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service. The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity. In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry. The patient was seen in consultation and felt to be a surgical candidate for improvement. Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication. The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table. Dose of antibiotics was given to the patient. Compression devices were placed on the lower extremities to prevent the knee embolic events. The patient was turned to 180 degrees. The ETT tube was secured and the area was then prepped and draped in usual sterile fashion. A head wrap was then placed on the position and we then began our local. Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access. Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves. This was done bilaterally. We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue. We continued down to the lateral orbital rim until we identified periosteum. We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially. Care was taken to preserve the infraorbital nerve and that was visualized after elevation. We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw. After this was then carried out, we then clipped and cut as well as the end of the screw. Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl. Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry. Excess skin along the incision was then removed as well the skin from just lateral to the canthus. Care was taken to leave the orbicularis muscle down. We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case. A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour. This was carried out using a 15 blade down to subcutaneous tissue. The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture. At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally. As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision. We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only. This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease. Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements. Dr. Y was available and participated in the portions of the case as well.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3949
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HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3950
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CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with "pins & needles" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3951
}
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REASON FOR CONSULTATION:, Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS: ,I am seeing the patient upon the request of Dr. Y. The patient is a very well known to me. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty. The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath. The patient was admitted and being treated for pneumonia, according to him. The patient denies any chest pain, chest pressure, or heaviness. Denies any palpitations, fluttering, or awareness of heart activity. However, on monitor, he was noticed to have PVCs random. He had run off three beats consecutive one time at 12:46 p.m. today. The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No fever or chills.,EYES: No visual disturbances.,ENT: No difficulty swallowing.,CARDIOVASCULAR: Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY: Cough and shortness of breath.,MUSCULOSKELETAL: Positive for arthritis and neck pain.,GU: Unremarkable.,NEUROLOGIC: Otherwise unremarkable.,ENDOCRINE: Otherwise unremarkable.,HEMATOLOGIC: Otherwise unremarkable.,ALLERGIC: Otherwise unremarkable.,PAST MEDICAL HISTORY:,1. Positive for coronary artery disease since 2002.,2. History of peripheral vascular disease for over 10 years.,3. COPD.,4. Hypertension.,PAST SURGICAL HISTORY:, Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1. Aspirin 81 mg daily.,2. Clopidogrel 75 mg daily.,3. Allopurinol 100 mg daily.,4. Levothyroxine 100 mcg a day.,5. Lisinopril 10 mg a day.,6. Metoprolol 25 mg a day.,7. Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION. HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:, No history of premature coronary artery disease. One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired. He has nine children, 25 grandchildren. He smokes one pack per day. He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.,NECK: Supple.,CARDIOVASCULAR: Upstroke is normal. Distal pulse symmetrical. Heart regular with a normal S1 with normally split S2. There is an S4 at the apex.,LUNGS: With decreased air entry. No wheezes.,ABDOMINAL: Benign. No masses.,EXTREMITIES: No edema, cyanosis, or clubbing.,NEUROLOGIC: Awake, alert, and oriented x3. No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3952
}
|
PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1. Sixty-percent rotator cuff tear, joint side.,2. Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1. Arthroscopic subacromial decompression.,2. Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff. The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon. This was confirmed later when the bursal side was opened up. Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion. He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:, He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope. With the scope in the posterior portal, the above findings were noted, and an anterior portal was established. A curved shaver was placed for debridement of the tear. I established this was about a 60-70% tear with a probable complete area of tear which was very small. There were no problems at the biceps or the rest of the joint. The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur. I did not debride the acromioclavicular joint. The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid. The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed. The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur. Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair. The shoulder was carried through a range of motion. I could see no evidence of impingement. Copious irrigation was carried out. The deltoid deep fascia was anatomically closed, as was the superficial fascia. The subcutaneous tissue and skin were closed in layers. A sterile dressing was applied. The patient appeared to tolerate the procedure well.surgery, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3953
}
|
INDICATIONS: ,Chest pain.,STRESS TECHNIQUE:,cardiovascular / pulmonary, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3954
}
|
TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula. She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein. She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P. She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T. She lives with her husband and she also has a son at home and she is a very active lady. She is right handed. The plan was to place an AV fistula at the left wrist. The risks and benefits were fully explained to her. She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically. Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist. The cephalic vein was exposed. The superficial branch of the radial artery was carefully protected and the radial artery was exposed. There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture. There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery. There were no complications.nephrology, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3955
}
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TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06. This was complicated by posterior capsule rupture. An intraocular lens implant was not attempted. He developed corneal edema and a preretinal hemorrhage. He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,POSTOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,ANESTHESIA: , General.,SPECIMEN: ,1. Donor corneal swab sent to Microbiology.,2. Donor corneal scar rim sent to Eye Pathology.,3. The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT: ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered. The patient was brought to the preoperative holding area, where the operative left eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced. The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. A lid speculum was placed. The posterior segment infusion was placed by the vitreoretinal service. Peritomy was performed at the 3 and 9 o'clock limbal positions. A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. The cornea was then measured and was found to accommodate a 7.5-mm trephine. The center of the cornea was marked. The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface. This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. Corneoscleral scissors were then used to excise completely the central cornea. The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. This was done without difficulty. At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. The 9-0 Prolene sutures double armed were then placed on each lens haptic loop. The keratoprosthesis was removed. Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. Wet-field cautery also was performed to achieve hemostasis. The leading hepatic sutures were then passed through the bed of the scleral flap. These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. The trailing hepatic was then placed into the posterior segment of the eye as well. The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. These were tied securely into position with the IOL nicely centered. At this point, the donor cornea punched at 8.25 mm was then brought into the field. This was secured with four cardinal sutures. The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. The knot was secured and buried after adequate tension was adjusted. The corneal graft was watertight. Attention was then turned back to the IOL sutures, which were locked into position. The ends were trimmed. The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. No complications were noted. The attending surgeon, Dr. X, performed the entire procedure. No complications of the procedure were noted. The intraocular lens was selected from preoperative calculations. No qualified resident was available to assist.ophthalmology, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3956
}
|
PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1. Atrophic dry cracked nasal mucosa.,2. Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess. The patient was taken to the operating room for incision and drainage. Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis. Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery. The patient does report of having endotracheal tube intubation during anesthesia. The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:, After the procedure was described, the patient was placed in the seated position. The fiberoptic nasal laryngoscope was then inserted into the patient's left naris. The nasal mucosal membranes were dry and atrophic throughout. There was no evidence of any mass lesions. The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity. There was no evidence of mass, ulceration, lesion, or obstruction. The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes. There was no evidence of any local mass lesion, nodule, or ulcerations. There was no evidence of any erythema. Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric. The airway was stable and patent throughout the entire examination. The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx. The eustachian tube was completely visualized and was patent without obstruction. The scope was then further removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris. At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma. If this becomes possible in the future, this may provide her some relief of her chronic dysphonia. The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.surgery, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3957
}
|
CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY: ,Noncontributory.,MEDICATIONS: ,None.,ALLERGIES: ,None.,PHYSICAL EXAMINATION: , GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine.,FINAL DIAGNOSIS:,1. First-degree and second-degree burns, right arm secondary to hot oil spill.,2. Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.general medicine, burn, workers' compensation industrial injury, workers' compensation, degree
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3958
}
|
CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:, A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly., ,PAST MEDICAL HISTORY:, Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.,General: A 70-year-old female who does not appear to be in acute distress. ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3959
}
|
PREOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,OPERATION:, Primary low-transverse C-section.,ANESTHESIA:, Epidural.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner. Anesthesia was tested and found to be adequate. Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally. Bleeders were bovied. Rectus muscles were separated from the overlying fascia with blunt and sharp dissection. Muscles were separated in the midline. Peritoneum was entered sharply and incision was carried out laterally in each direction. Bladder blade was placed and bladder flap developed with blunt and sharp dissection. A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction. Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance. Infant was carefully suctioned after delivery of the head and body. Cord blood was collected. _______ and endometrial cavity was wiped free of membranes and clots. Lower segment incision was inspected. There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic. Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present. Cul-de-sac was suctioned free of blood and clots and irrigated. Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated. Lower segment incision was again inspected and found to be hemostatic. The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin. Hemostasis was present between all layers. The area was gently irrigated across the peritoneum and fascial layers. There were no intraoperative complications except blood loss. The patient was taken to the recovery room in satisfactory condition.obstetrics / gynecology, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3960
}
|
PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.neurosurgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3961
}
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CHIEF COMPLAINT:, The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:, She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:, Prenatal vitamins.,ALLERGIES:, She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS: Weight: 124 pounds. Blood pressure 96/54. Pulse: 72. Respirations: 16. LMP: 10/18/03. Age: 39.,HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation. She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen: Soft. No masses.,Pelvic: Uterus is involuting.,Rectal: She has one external hemorrhoid which has inflamed. Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:, Satisfactory three-week postpartum course, seasonal allergies. We will try Patanol eyedrops and Allegra 60 mg twice a day. She was cautioned about the possibility that this may alter her milk supply. She is to drink extra fluids and call if she has problems with that. We will try ProctoFoam HC. For the hemorrhoids, also increase the fiber in her diet. That prescription was written, as well as one for Allegra and Patanol. She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon. She will call and return if she continues to have problems with allergies. Meantime, rechecking in three weeks for her final six-week postpartum checkup.soap / chart / progress notes, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3962
}
|
CHIEF COMPLAINT:,1. Metastatic breast cancer.,2. Enrolled is clinical trial C40502.,3. Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502. She was randomized to the ixabepilone plus Avastin. She experienced dose-limiting toxicity with the fourth cycle. The Ixempra was skipped on day 1 and day 8. She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy. Early in the month she had concerned about possible perforated septum. She was seen by ENT urgently. She was found to have nasal septum intact. She comes into clinic today for day eight Ixempra.,CURRENT MEDICATIONS: ,Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,ALLERGIES: ,Compazine.,REVIEW OF SYSTEMS: , The patient is comfort in knowing that she does not have a septal perforation. She has progressive neuropathy and decreased sensation in her fingertips. She makes many errors when keyboarding. I would rate her neuropathy as grade 2. She continues to have headaches respond to Ultram which she takes as needed. She occasionally reports pain in her right upper quadrant as well as right sternum. He denies any fevers, chills, or night sweats. Her diarrhea has finally resolved and her bowels are back to normal. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:hematology - oncology, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3963
}
|
HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rectal bleeding. She was brought to the Hospital with some loose stool. She was found to be dehydrated. She was given IV fluid bolus, but then she started bleeding from G-tube site. There was some fresh blood coming out of the G-tube site. She was transferred to PICU. She is hypertensive. Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007. Right above knee amputation.,ALLERGIES:, None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:, Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000. KUB showed large stool with dilated small and large bowel loops. Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1. Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000. PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL: She is intubated.,HEENT: Atraumatic. She is intubated.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Distended. Decreased bowel sounds.,GENITALIA: Grossly normal female.,CNS: She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy. She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN: ,Plan is to give vitamin K, FFP, blood transfusion. Consider upper endoscopy. Procedure and informed consent discussed with the family.gastroenterology, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3964
}
|
POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3965
}
|
DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge.discharge summary, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3966
}
|
INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted.,SUMMARY:,1. Nondiagnostic adenosine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION:, Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 58% by gated SPECT.radiology, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3967
}
|
CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73. HR 71. RR 21. Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits.neurology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3968
}
|
PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:, Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus. She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table. The face was prepped with pHisoHex draped. The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology. The report was "basal cell carcinoma with all margins free of tumor." Hemostasis was controlled with the Bovie. Excised lesion diameter was 1.2 cm. The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin. The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin. Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment. The patient was returned to the recovery room in satisfactory condition. She tolerated the procedure satisfactorily, and then no complications. Blood loss was essentially nil.surgery, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3969
}
|
CHIEF COMPLAINT:, Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation.,3. History of congestive heart failure.,4. History of schwannoma resection. It was resected from T12 to L1 in 1991.,5. He has chronic obstruction of his inferior vena cava.,6. Recurrent lower extremity cellulitis.,SOCIAL HISTORY: ,He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3970
}
|
PREOPERATIVE DIAGNOSIS:, End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:, Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY: ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition. She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein. After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room, placed supine on the operating table. After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion. A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife. The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues. This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion. Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection. The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein. There was noted to be excellent flow through the vein. A pocket was then created just lateral to the incision in the subcutaneous tissue. The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures. The bed of dissection of the basilic vein was then treated with fibrin sealant. The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion. The skin was closed using 4-0 Monocryl suture for a subcuticular stitch. Dermabond was applied to the incision. Again, there was noted to be good palpable thrill throughout the superficialized vein. The patient was then awakened, and taken to the recovery room in stable condition.surgery, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3971
}
|
CHIEF COMPLAINT:, Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:, This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed. His last exacerbation was 04/04. He has been very competitive in his sports this spring and summer and has had no issues since that time. He eats well from all food groups. He has very good calcium intake. He will be attending Maize High School in the ninth grade. He has same-sex and opposite-sex friends. He has had a girlfriend in the past. He denies any sexual activity. No use of alcohol, cigarettes or other drugs. His bowel movements are without problems. His immunizations are up to date. His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:, As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional: He has had no fever.,HEENT: No vision problems. No eye redness, itching or drainage. No earache. No sore throat or congestion.,Cardiovascular: No chest pain.,Respiratory: No cough, shortness of breath or wheezing.,GI: No stomachache, vomiting or diarrhea.,GU: No dysuria, urgency or frequency.,Hematological: No excessive bruising or bleeding. He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General: He is alert and in no distress.,Vital signs: He is afebrile. His weight is at the 75th percentile. His height is about the 80th percentile.,HEENT: Normocephalic. Atraumatic. Pupils are equal, round and reactive to light. TMs are clear bilaterally. Nares patent. Nasal mucosa is mildly edematous and pink. No secretions. Oropharynx is clear.,Neck: Supple.,Lungs: Good air exchange bilaterally.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Male. Testes descended bilaterally. Tanner IV. No hernia appreciated.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. Minor sunburn on upper back.,Neurological: Grossly intact.,ASSESSMENT:,1. Well child.,2. Asthma with good control.,3. Allergic rhinitis, stable.,PLAN:, Hearing and vision assessment today are both within normal limits. Will check an H&H today. Continue all medications as directed. Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue. Anticipatory guidance for age. He is to return to the office in one year or sooner if needed.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3972
}
|
PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed. She is married. She is in sales. She does not smoke. She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec. She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:, Negative for heart, lungs, GI, GU, cardiac, or neurologic. Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile. Vital Signs are stable. HEENT: EOMI. PERRLA. Neck is soft and supple. Lungs clear to auscultation. She is mildly tender in the abdomen in the right upper quadrant. No rebound. Abdomen is otherwise soft. Positive bowel sounds. Extremities are nonedematous. Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications. She understands and we will proceed with the surgery in the near future.,gastroenterology, laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3973
}
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PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure. Oxygenation was given. The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE: ,The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine. The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***. Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves. Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue. After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was used throughout the procedure.,COMPLICATIONS:, None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.pain management, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1. Open reduction internal fixation of the talus.,2. Medial malleolus osteotomy.,3. Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:, 50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:, A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament. There was no evidence of osteochondral defects of the talar dome.,HISTORY: ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply, the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03. A spinal anesthetic was administered. A nonsterile tourniquet was placed on the left upper thigh, but not inflated. He was then positioned on the beanbag. The extremity was then prepped and draped in the usual sterile fashion for this procedure. An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg. At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site. At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus. This was curved anteromedial along the root of the saphenous vein. The saphenous vein was located. Its tributaries going plantar were cauterized and the vein was retracted anterolaterally. At this time, we identified the medial malleolus. There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus. This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem. It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact. This pedicle was the anterior portion of the deltoid ligament. At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus. Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply. This provided us with excellent exposure to the fracture site of the medial side. At this time, any loose comminuted pieces were removed. The dome of the talus was also checked and did not reveal any osteochondral defects. There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site. It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site. At this time, a reduction was performed. The #7-0 partially threaded cannulated screws were used in order to fix the fracture. At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site. Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in. A depth gauze was then used to measure screw length. A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw. A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site. Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction. This projection gave us excellent view of our screw placement and excellent compression across the fracture site. At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft. This was placed using a freer elevator into the fracture site where the comminution was. At this time, we copiously irrigated the wound. The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps. Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws. Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury. A tight repair was performed of the deltoid ligament. At this time, again copious irrigation was used to irrigate the wound. A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision. At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied. The patient was then placed in a plaster splint for mobilization. The tourniquet was then released. The patient was then transferred off the operating table to recovery in stable condition. The prognosis for this fracture is guarded. There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk. The patient is aware of this and he will be followed as an outpatient for this problem.surgery, deltoid ligament, medial malleolus osteotomy, open reduction internal fixation of the talus, hawkins iv talus fracture, medial malleolus, fracture site, malleolus, talus, medial, fracture, tourniquet, ligament, osteotomy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3975
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DELIVERY NOTE:, This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation at 1900 At this time, a bulging bag was noted, which ruptured and thick meconium was present. At 1937 hours, she delivered a viable male infant, left occiput, anterior. Mouth and nares suctioned well with a DeLee on the perineum. No nuchal cord present. Shoulders and body followed easily. Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance. Apgars 9 and 9. Pitocin 15 units infused via pump protocol. Placenta followed complete and intact with fundal massage and general traction on the cord. Three vessels are noted. She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area. Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL. The remainder of the lacerations was not at all bleeding and no other lacerations present. Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly. EBL was about 500 mL. Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically. Mom and baby currently doing very well.obstetrics / gynecology, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
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EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Unremarkable exam; specifically no evidence for acute appendicitis. ,2. No acute nephro-/ureterolithiasis. ,3. No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.gastroenterology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct
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HISTORY OF PRESENT ILLNESS: , I have seen ABC today. He is a very pleasant gentleman who is 42 years old, 344 pounds. He is 5'9". He has a BMI of 51. He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again. He wants to be able to exercise and play volleyball. Physically, he is sluggish. He gets tired quickly. He does not go out often. When he loses weight he always regains it and he gains back more than he lost. His biggest weight loss is 25 pounds and it was three months before he gained it back. He did six months of not drinking alcohol and not taking in many calories. He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago.,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure. He has asthma and difficulty walking two blocks or going eight to ten steps. He has sleep apnea and snoring. He is a diabetic, on medication. He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling. He has hemorrhoids.,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery.,SOCIAL HISTORY: , He is currently single. He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink. He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,FAMILY HISTORY: , Obesity, heart disease, and diabetes. Family history is negative for hypertension and stroke.,CURRENT MEDICATIONS:, Include Diovan, Crestor, and Tricor.,MISCELLANEOUS/EATING HISTORY: ,He says a couple of friends of his have had heart attacks and have had died. He used to drink everyday, but stopped two years ago. He now only drinks on weekends. He is on his second week of Chantix, which is a medication to come off smoking completely. Eating, he eats bad food. He is single. He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m. He currently weighs 344 pounds and 5'9". His ideal body weight is 160 pounds. He is 184 pounds overweight. If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin. He also is positive for gout. He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA. He denies venous insufficiency or thrombophlebitis. Denies shortness of breath, COPD, or emphysema. Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION: ,He is alert and oriented x 3. Cranial nerves II-XII are intact. Neck is soft and supple. Lungs: He has positive wheezing bilaterally. Heart is regular rhythm and rate. His abdomen is soft. Extremities: He has 1+ pitting edema.,IMPRESSION/PLAN:, I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications. He understands. He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass. He will need to get a letter of approval from Dr. XYZ. He will need to see a nutritionist and mental health worker. He will need an upper endoscopy by either Dr. XYZ. He will need to go to Dr. XYZ as he previously had a sleep study. We will need another sleep study. He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar. After this is performed, we will submit him for insurance approval.consult - history and phy., laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight,
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{
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"dataset_name": "medical-transcription-40",
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ADMISSION DIAGNOSIS:, End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:, Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY: ,1. Diabetes mellitus diagnosed 12 years ago.,2. Hypertension.,3. Coronary artery disease with a myocardial infarct in September of 2006.,4. End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY: ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:, Hypertension.,PHYSICAL EXAMINATION: ,GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR: Regular rate and rhythm.,PULMONARY: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit. Initially, the patient had a decrease in hematocrit from 30 to 25. The patient's hematocrit stabilized at 25. During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3. The patient was making excellent urine throughout his stay. The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor. The patient was advanced in diet appropriately. The patient was started on Prograf by postoperative day #2. Initial Prograf levels came back high at 18. The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home. During the patient's stay, the patient received four total doses of Thymoglobulin. Today, he will complete his final dose of Thymoglobulin prior to being discharged. In addition, today, the patient has an elevated blood pressure of 198/96. The patient is being given an extra dose of metoprolol for this blood pressure. In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin. These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.nan
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PREOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Negligible.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines. In the preoperative area, the patient received pilocarpine drops. The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain. Approximately 3 mL were given. The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye. During the draping process, care was taken to isolate the lashes. A screw type speculum was inserted to maintain patency of lids. A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade. This was approximately one-half scleral depth in thickness. A crescent blade was then used to dissect forward the clear cornea. Hemostasis was again achieved with wet-field cautery. A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. The site was then profusely irrigated with balanced salt solution. A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed. Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps. The iris was then repositioned into the eye and the anterior chamber was inflated with BSS. The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle. BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. Antibiotic and steroid drops were placed in the eye as was homatropine 5%. The antibiotic consisted of Vigamox and the steroid was Econopred Plus. A patch and shield were placed over the eye after the drape was removed. The patient was taken to the recovery room in good condition. She will be seen in followup in the office tomorrow.ophthalmology, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,
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{
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"id": 3980
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CHIEF COMPLAINT:, Arm and leg jerking.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:, Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups. This patient has developed some upper airway congestion in the past day. She has not had any vomiting or diarrhea. Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds. This patient has not had any rashes. Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit. Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps. There were no complications during pregnancy such as diabetes or hypertension. Prenatal care started at approximately 3 weeks, and mom maintained all visits. She also denies any smoking, alcohol, or drug use during the pregnancy. Mom was GBS status positive, but denies any other infections such as urinary tract infections. She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis. After delivery, this patient did not receive antibiotics secondary to "borderline labs." She was jaundiced after birth and received photo treatments. Her discharge bilirubin level was approximately 11. Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad. She specifically denies any blistering, herpetic genital lesions. She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:, Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:, Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:nan
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{
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CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.nan
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}
|
EXAM: , OB Ultrasound.,HISTORY:, A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.obstetrics / gynecology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3983
}
|
SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals: Weight was 130 pounds and blood pressure 124/78.,HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was erythematous and swollen. Only clear drainage was seen. TMs were clear.,Neck: Supple without adenopathy.,Lungs: Clear.,ASSESSMENT:, Allergic rhinitis.,PLAN:,1. She will try Zyrtec instead of Allegra again. Another option will be to use loratadine. She does not think she has prescription coverage so that might be cheaper.,2. Samples of Nasonex two sprays in each nostril given for three weeks. A prescription was written as well.soap / chart / progress notes, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3984
}
|
REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1. Amiodarone 200 mg once a day.,2. Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES: ,CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS: ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3985
}
|
PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES: ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA: ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin. The patient had buried penis with significant obesity issues in the suprapubic area. Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed. The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix. Consent had been obtained. Risk of scarring, decrease in penile sensation, and unexpected complications were discussed. The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc. Consent was obtained.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in usual sterile fashion. Local MAC anesthesia was applied. After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block. The patient had significant phimosis and slight ventral chordee. Using marking pen, the excess foreskin was marked off. Using a knife, the ventral chordee was released. The urethra was intact. The excess foreskin was removed. Hemostasis was obtained using electrocautery. A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done. The patient tolerated the procedure well. There was excellent hemostasis. The penis was straight. Vaseline gauze and Kerlix were applied. The patient was brought to the recovery in stable condition. Plan was for removal of the dressing tomorrow. Okay to shower after 48 hours.surgery, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3986
}
|
CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.neurology, loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3987
}
|
CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes.,SOCIAL HISTORY: , The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:consult - history and phy., t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3988
}
|
PREOPERATIVE DIAGNOSIS:, Right spermatocele.,POSTOPERATIVE DIAGNOSIS: ,Right spermatocele.,OPERATIONS PERFORMED:,1. Right spermatocelectomy.,2. Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: ,The patient is a 77-year-old male who comes to the office with a large right spermatocele. The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove. Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed. The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down. The patient was told about the risk of recurrence of spermatocele. The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion. A midline scrotal incision was made measuring about 2 cm in size. The incision was carried through the dartos through the scrotal sac and the spermatocele was identified. All the layers of the spermatocele were removed. Clear layer was visualized, was taken all the way up to the base, the base was tied. Entire spermatocele sac was removed. After removing the entire spermatocele sac, hemostasis was obtained. The testicle was not in normal orientation. The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle. The testicle was placed in a normal orientation. Careful attention was drawn not to twist the cord. Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations. Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period. The dartos was closed using 2-0 Vicryl in running locking fashion. There was excellent hemostasis. The skin was closed using 4-0 Monocryl. Dermabond was applied. The patient tolerated the procedure well. The patient was brought to the recovery room in stable condition.urology, orchidopexy, spermatocele, spermatocelectomy, scrotal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3989
}
|
OPERATION PERFORMED:, Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,POSTOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,3. Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: ,1 hour and 22 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort. Mom reported history of high fever after surgery and he has one seizure previously. He has history of trauma to his front teeth and physician put him on antibiotics. He was only cooperative for having me do a visual examination on his anterior teeth. Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted. Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION: ,The child was brought to the Hospital Day Surgery accompanied by his mother. There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment. After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment. The patient's history and physical examination was reviewed. He was given factor for appropriately for his hemophilia prior to being taken back to the operating room. Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with an oral tube and the tube was stabilized. The head was wrapped and IV was started. The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph. After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste. The patient's teeth were rinsed well. The patient's oral cavity was suctioned clean. Clinical and radiographic examination followed and areas of decay were noted. During the restorative phase, these areas of decay were incidentally removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________ bonded with a one-step bonding agent. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted. The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies. Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth. At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental carries were present on the following teeth: Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries. The remainder of his teeth and soft tissues were within normal limits. The following restoration and procedures were performed. Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite. Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam. Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother. She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3990
}
|
CHIEF COMPLAINT: ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:, This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well. The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do. The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house. The patient states that she just simply felt funny and does not give any more specific details than this. The patient denies any pain at any time. She did not have any shortness of breath. No nausea or vomiting. No generalized weakness. The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go. The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved. The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF. The patient was discharged home after evaluation in the emergency room. The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician. The patient denies having any other symptoms today. The patient denies any fever or chills. Has not had any recent weight change. HEENT: The patient denies any headache. No neck pain. No rhinorrhea. No sinus congestion. No sore throat. No any vision or hearing change. No eye or ear pain. CARDIOVASCULAR: The patient denies any chest pain. RESPIRATIONS: No shortness of breath. No cough. No wheeze. The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No change in the bowel movements. There has not been any diarrhea or constipation. No melena or hematochezia. GENITOURINARY: No dysuria, hematuria, urgency, or frequency. MUSCULOSKELETAL: No back pain. No muscle or joint aches. No pain or abnormalities to any portion of the body. SKIN: No rashes or lesions. NEUROLOGIC: The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days. The patient denies any dizziness at this time. No syncope or no near-syncope. The patient denies any focal weakness or numbness. No speech change. No difficulty with ambulation. The patient has not had any vision or hearing change. PSYCHIATRIC: The patient denies any depression. ENDOCRINE: No heat or cold intolerance.,PAST MEDICAL HISTORY:, COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:, Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago. The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear sclerae and cornea bilaterally. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx are normal without any sign of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. No cervical lymphadenopathy. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +2. The patient does have +1 bilateral lower extremity edema. RESPIRATIONS: The patient has coarse breath sounds bilaterally, but no dyspnea. Good air movement. No wheeze. No crackles. The patient speaks in full sentences without any difficulty. The patient does not exhibit any retractions, accessory muscle use or abdominal breathing. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy. MUSCULOSKELETAL: No abnormalities noted to the back, arms or legs. SKIN: No rashes or lesions. NEUROLOGICAL: Cranial nerves II through XII are intact. Motor is 5/5 and equal to bilateral arms and legs. Sensory is intact to light touch. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her. The patient has normal mood and affect. HEMATOLOGIC AND LYMPHATIC: There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture. There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08. CBC has no specific abnormalities of issue. Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20. The rest of the values are normal and unremarkable. LFTs are all within normal limits. Cardiac enzymes are all within normal limits. Digoxin level is therapeutic at 1.6. Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago. CAT scan of the head did not identify any acute abnormalities. I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day. I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past. The neighbor is XYZ and he says that he checks on her three times a day every day. ABC is the patient's son and although he lives out of town he calls and checks on her every day as well. He states that he spoke to her yesterday. She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician. She sounded her usual self to him. Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him. He states that he will be able to check on her tomorrow as well. Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements. The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well. The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1. EARLY DEMENTIA.,2.nan
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"dataset_name": "medical-transcription-40",
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TITLE OF OPERATION:, Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07. Subsequently, biopsy confirmed tumor persistence in the right glottic region. Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail. Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level. The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives. He was accompanied by his wife and daughter. Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table. After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm. A #6 endotracheal tube was placed initially. Direct laryngoscopy was performed with a Lindholm laryngoscope. A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis. Subsequently, a decision was then made to go ahead and perform the surgical intervention. A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected. A shoulder roll was applied after the patient was prepped and draped in a sterile fashion. Subsequently, a hemi-apron incision was performed. Subplatysmal flaps were raised at the hyoid bone into the clavicle. Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed. Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle. Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle. The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified. Level 2A contents were then dissected off the floor of the neck including levels 3 and 4. Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4. The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve. Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed. Subsequently, the strap muscles were separated in the midline. The trachea was identified in the midline. The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage. Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively. The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular. Attention was then turned to performing a cricothyrotomy. Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision. A #7 anode tube was then placed in this area and secured. Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis. Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine. It was evident that this tumor had extended more than 1 cm into the subglottic region. Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded. Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy. Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin. A W-plasty was also performed to allow for enlargement of the stoma. Attention was then turned to identifying the common parting wall of the trachea and the esophagus. Attention was then turned to resecting the hyoid bone. The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism. The wound was copiously irrigated. Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect. Once this was performed, a running 3-0 canal stitch was used to close the pharynx. Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied. Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon. The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin. The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.ent - otolaryngology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage
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REASON FOR CONSULTATION:, Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness. No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1. Metformin.,2. Prilosec.,3. Folic acid.,4. Flomax.,5. Metoprolol.,6. Crestor.,7. Claritin.,ALLERGIES:, DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:, Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors.,HEENT: No history of cataract or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena.,UROLOGICAL: Frequency, urgency.,MUSCULOSKELETAL: No muscle weakness.,SKIN: None significant.,NEUROLOGICAL: No TIA or CVA. No seizure disorder.,PSYCHOLOGICAL: No anxiety or depression.,ENDOCRINE: As above.,HEMATOLOGICAL: None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic, normocephalic.,NECK: Veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft, nontender. Bowel sounds present.,EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis.,CNS: Benign.,EKG: nan
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REASON FOR VISIT:, The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped. Vitamin D and calcium over the counter, we need to verify that. Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:, On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress. There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum. Stasis dermatitis changes in both lower extremities present. Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well. Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228. Her microcytosis and hypochromia has resolved. Her serum electrophoresis does not show a monoclonal abnormality. Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation. This points again towards some ileum pathology. Her ANCA B and C were negative. Her PF3 and MPO were unremarkable. Her endomysial antibodies were negative. Her sed rate at this time were 19. The highest has been 30, but prior to her appointment here was even higher. Her ANA continues to be positive with a titer of 1:40, speckled pattern. Her double-stranded DNA is negative. Her serum immunofixation confirmed the absence of monoclonal abnormality. Her urine immunofixation was not performed. Her IgG, IgA, and IgM levels are normal. Her IgE levels are normal as well. A urinalysis was not performed this time. Her CRP is 0.4. Her tissue transglutaminase antibodies are negative. Her ASCA is normal and anti-OmpC was not tested. Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific. I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal. Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency. Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30. Her TIBC was 345 pointing towards an iron deficiency anemia. I am reminding you that her ACE levels in the past were normal and that she has a microcytosis. Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive. Her pelvic ultrasound showed normal uterus adnexa. Her bladder was normal as well. Subcentimeter inguinal nodes were found. There was no large lytic or sclerotic lesion noted. Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease. Her capsule endoscopy was limited secondary to rapid transit. There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum. However, no significant inflammation or bleeding was seen and this could be small bowel crisis. Neither evidence of bleeding or inflammation were seen as well. Specifically, the terminal ileum appeared normal. Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:, This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004. She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers. Since I took over her care, I have not seen a clear-cut erythema nodosum being present. No evidence of synovitis was there. Her serologies apart from an ANA of 1:40 were negative. She has a livedo pattern, which has been worrisome. The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency. She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV. We never received the x-ray of her hands which she had and she never had a DEXA scan. Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well. Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal. We are going check a PPD to rule out tuberculosis. We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern. An anti-intrinsic factor will be added as well. Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency. In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash. Regarding her heart murmur, we are going to proceed with an echocardiogram. A PPD should be placed as well. In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:, 1. Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2. Iron deficiencies, according to iron studies.,3. Borderline B12 with increased methylmalonic acid and homocystine.,4. On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5. Typical ANCA, per records, were not verified here. ANCA and ASCA were negative and the OmpC was not ordered.,6. Acne.,7. Recurrent arthralgia not present. Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8. Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today. Needs vaccination for influenza and pneumonia.,9. Vitamin D deficiency. She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10. Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:, We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies. We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly. We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome. She should be taking vitamin D and calcium after the completion of vitamin D replacement. She should be seen by her primary care physician, have the iron and B12 deficiency worked up. She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist. Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies. Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum. An anti-intrinsic factor would be added, as I mentioned. I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers. She does not give a history of oral contraceptives or medications that could be related to erythema nodosum. She does not have any evidence of lupus __________ mycosis. Histoplasmosis coccidioidomycosis would be accompanied by other symptoms. Hodgkin disease has probably been ruled out with a CAT scan. However, we are going to add an LDH in future workup. I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy. The patient will return in 1 month.nan
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PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1. Open septorhinoplasty with placement of bilateral spreader grafts.,2. Placement of a radiated rib tip graft.,3. Placement of a morcellized autogenous cartilage dorsal onlay graft.,4. Placement of endogen, radiated collagen dorsal onlay graft.,5. Placement of autogenous cartilage columellar strut graft.,6. Bilateral lateral osteotomies.,7. Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8. Fracture of right upper lateral cartilage.,ANESTHESIA: ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,100 mL.,URINE OUTPUT:, Not recorded.,SPECIMENS:, None.,DRAINS: , None.,FINDINGS: ,1. The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2. The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3. The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity. The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity. He was found to have a C-shaped deformity to the left as well as some tip ptosis. The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table. The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty. The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees. Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally. The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally. Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision. This incision was made using a #15 blade. A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura. However, there was a dissection injury to the left medial crura. Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage. Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion. Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions. There was also an obvious fracture of the right upper lateral cartilage. There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump. The skin was contributing to the patient's cosmetic deformity. In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage. This mucocele was attempted to be dissected free, most of which was removed via dissection. We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome. The dorsal hump was taken down and passed off the table. Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage. This was passed off to use later for possible onlay grafts. There was now a marked open roof deformity of the cartilage and bony sprue. A septoplasty was then performed throughout and a Kelly incision on the right side. Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side. A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut. This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities. The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally. Once these were placed, we then proceeded to work on the bony open roof. Lateral osteotomies were made with 2-mm osteotomes bilaterally. The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum. We then proceeded to the tip. A cartilaginous strut was then fashioned from the cartilaginous septum. It was approximately 15 mm long. This was placed, and a pocket was just formed between the medial crura. This pocket was taken down to the nasal spine, and then, the strut graft was placed. The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition. The intradermal sutures were then placed to help to align the nasal tip. The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing. Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot. The patient had good tip support after this maneuver. We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome. This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen. The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft. Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages. Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts. This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness. There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point. The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion. The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture. Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture. The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct. A Denver external splint was then applied. The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3995
}
|
PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux. The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration. He has failed outpatient antibiotic therapy and conservative methods. At this time, he desires to attempt surgical correction. The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone. He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively. The wound was on the planar medial, distal and dorsal medial. The wound's bases were fibrous. They did not break the bone at this point. They were each approximately 0.5 cm in diameter. After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied. Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block. Next, the foot was prepped and draped in the usual aseptic fashion. It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected. Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium. Next, the incision was deepened through the subcutaneous tissue. A heavy amount of bleeding was encountered. Therefore, a Penrose drain was applied at the tourniquet, which failed. Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis. Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery. Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon. The long extensor tendon was thickened and overall exhibited signs of hypertrophy. The transverse incision through the long extensor tendon was made with a #15 blade. Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint. Next, the extensor tendon was peeled dorsally and distally off the bone. Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx. This bone was removed with a sharp dissection. Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx. This was passed off as the infected bone specimen for microbiology and pathology. Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx. Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins. The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline. Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin. This bone was found to be hard and healthy appearing. The wound after irrigation was free of all debris and infected tissue. Therefore anaerobic and aerobic cultures were taken and sent to microbiology. Next, OsteoSet beads, tobramycin-impregnated, were placed. Six beads were placed in the wound. Next, the extensor tendon was re-approximated with #3-0 Vicryl. The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits. A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap. The patient tolerated the above anesthesia and procedure without complications. He was transported via a cart to the Postanesthesia Care Unit. His vitals signs were stable and vascular status was intact. He was given a medium postop shoe that was well-formed and fitting. He is to elevate his foot, but not apply ice. He is to follow up with Dr. X. He was given emergency contact numbers. He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home. The patient was discharged in stable condition.podiatry, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3996
}
|
HISTORY OF PRESENT ILLNESS:, The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis. We corrected her hematocrit last year with intravenous (IV) iron. Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis. Her course has been very complicated since then with needing multiple surgeries for removal of hematoma. This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:, Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000. MCV is 89. Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000. Her hematocrit has been essentially stable for the past month or so. White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0. This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV. The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated. ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16. Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7. Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941. Folic acid was normal. Iron saturation has not been checked since March, and was normal then. Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007. She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL: She is alert, and frustrated with her prolonged hospital stay. She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS: Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95. She is not requiring oxygen.,SKIN: No significant ecchymoses are noted.,ABDOMEN: Ileostomy is in place, with greenish black liquid output. Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES: She has no peripheral edema.,CARDIAC: Regular rate.,LYMPHATICS: No adenopathy is noted.,LUNGS: Clear bilaterally.,IMPRESSION AND PLAN:, Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K. I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT. I will check a PTT and check mixing studies if that is prolonged. It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting. I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count. I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial. Given her decreased creatinine clearance, I agree with erythropoietin support. She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again. She has had part of her small bowel removed, so there may be a component of poor absorption as well. If she is iron deficient, this may contribute also to her elevated platelet counts. I will check a ferritin. This may be difficult to interpret because of inflammation. If it is decreased, plan will be to add iron supplementation intravenously. If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery. She is not a surgical candidate now with her elevated PT/INR.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3997
}
|
PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA: ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION: ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon. There was some softening and loss of the articular cartilage over the glenoid. The labrum was ________ attached permanently to the glenoid. The biceps tendon was nonsubluxable. Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side. Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space. There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:, This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder. MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position. After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion. The left extremity was prepped and draped in usual fashion. The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect. We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion. A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder. A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula. The operative findings found intra-articularly were as described previously gross operative findings. We did not see any evidence of acute pathology. We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline. The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal. All this was done and hemostasis was achieved. The rotator cuff was examined from the bursal side and showed no evidence of tears. There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver. We removed all of our instruments and suctioned the subacromial space dry. A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling. She was placed back on the gurney, extubated and taken to the PACU in stable condition.surgery, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 3998
}
|
ABNORMAL CHOLESTEROL RESULT LETTER,Recently you had a cholesterol test done. The cholesterol levels were abnormal. These are usually associated with increased risk for stroke and heart attack. I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best step. I would like you to make an appointment, if you are interested in treatment for this. There are several treatment options available at this time. Diet is one of the options, although there is limited reduction in total cholesterol and LDL cholesterol with dieting. Most of the time under strict diet patients can achieve a 15% reduction in cholesterol. If your cholesterol levels are moderate to severely elevated, usually diet is not the first line of therapy. If you are diabetic or have hypertension these two also increase your risk with the combination of hypercholesterolemia. Most of the time cholesterol that is elevated is from your genetic background and is independent of diet. New research shows that treatment of high cholesterol can decrease your risk of developing Alzheimer’s disease.,Again, I am recommending at least we discuss medical treatment for hypercholesterolemia. Please consider calling for a followup appointment concerning your cholesterol levels. If you should have any further questions, please do not hesitate to contact me. I am enclosing a copy of your lab results for your review.letters, letter, ldl, abnormal, cholesterol, cholesterol level, cholesterol test, heart attack, hypercholesterolemia, increased risk, lab results, stroke, total cholesterol, abnormal cholesterol result, abnormal cholesterol, cholesterol levels, levels, treatment, dietNOTE,: 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": 3999
}
|
EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.radiology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord
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