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EXAM: , Right foot series.,REASON FOR EXAM: ,Injury.,FINDINGS: , Three images of the right foot were obtained. On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal. Also on a single image, there is a lucency seen ... | Podiatry | 31 |
EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS: ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. | Orthopedic | 27 |
There is normal and symmetrical filling of the caliceal system. Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally. The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying... | Urology | 39 |
CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS: ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He ... | General Medicine | 15 |
CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The sym... | General Medicine | 15 |
HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Wa... | Bariatrics | 2 |
PREOPERATIVE DIAGNOSIS:, Right renal stone.,POSTOPERATIVE DIAGNOSIS: ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:, Minimal. The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presente... | Nephrology | 21 |
PREPROCEDURE DIAGNOSIS:, Change in bowel function.,POSTPROCEDURE DIAGNOSIS:, Proctosigmoiditis.,PROCEDURE PERFORMED:, Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable. ,INDICATIONS:, The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is he... | Surgery | 38 |
HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion def... | Orthopedic | 27 |
PREOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,OPERATION PERFORMED:, Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:, Local with IV sedation.,COMPLICATIONS:, None.,SUMMARY: , The patient in the operating r... | Surgery | 38 |
PREOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,ANESTHESIA: ,General endotracheal.,ENDOSCOPIC FINDINGS:,1. Normal true vocal cords.,2. Subglottic stenosis down to 5 mm with mature cicatrix.,3. Tracheal granulation... | Surgery | 38 |
PREOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac cre... | Surgery | 38 |
DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypot... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSIS: ,Lateral epicondylitis. | Surgery | 38 |
HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He state... | Consult - History and Phy. | 5 |
PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:, Nasotracheal general anesthesia.,IV FLUIDS:, A 7... | Surgery | 38 |
HISTORY OF PRESENT ILLNESS:, The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension. According to the patient, s... | General Medicine | 15 |
EXAM:, Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are gr... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopector... | Surgery | 38 |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses... | Obstetrics / Gynecology | 24 |
HISTORY:, A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physi... | Allergy / Immunology | 0 |
PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,AN... | Surgery | 38 |
POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed. The patient has been ambulating without difficulty. The patient is still NPO. The patient denies any new symptomatology from 6/10/2009. The patient has complaints of incisional tenderness. ... | Obstetrics / Gynecology | 24 |
TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-... | Orthopedic | 27 |
PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:, Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magni... | Surgery | 38 |
PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible b... | Cardiovascular / Pulmonary | 3 |
CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1. Posttransplant lymphoproliferative disorder.,2. Chronic renal insufficiency.,3. Squamous cell carcinoma of the skin.,4. Anemia secondary to chronic renal insufficiency and chemotherapy.,5. Hypertension.,HISTORY OF PRESENT ILL... | Hematology - Oncology | 16 |
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 ... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSES:,1. Enlarging nevus of the left upper cheek.,2. Enlarging nevus 0.5 x 1 cm, left lower cheek.,3. Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1. Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2. Excision of the left lower cheek ... | Surgery | 38 |
XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC. Mr. ABC is being referred for evaluation of glaucoma. The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally. The patient's visual fields are full to confronta... | Letters | 20 |
PROCEDURE PERFORMED:,1. Right heart catheterization.,2. Left heart catheterization.,3. Left ventriculogram.,4. Aortogram.,5. Bilateral selective coronary angiography.,ANESTHESIA:, 1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:, The patient is a 48-year-old female with severe mitral stenosis diag... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a re... | Surgery | 38 |
PREOPERATIVE DIAGNOSIS:, Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,A 35-year-old female, P4-0-0-4, who... | Surgery | 38 |
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 inserti... | General Medicine | 15 |
EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks an... | Office Notes | 25 |
PREOPERATIVE DIAGNOSES:, Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:, Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:, Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal ... | Surgery | 38 |
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 t... | General Medicine | 15 |
TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralizatio... | Radiology | 33 |
PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruc... | Surgery | 38 |
CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS: ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient n... | General Medicine | 15 |
SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heart... | Consult - History and Phy. | 5 |
REASON FOR EXAM: This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE: The procedure risks and possible complications including, but not limited to severe hemor... | Surgery | 38 |
ADMISSION DIAGNOSIS:, Morbid obesity. BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity. BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years. She has made m... | Bariatrics | 2 |
PREOPERATIVE DIAGNOSIS:, C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper ... | Neurosurgery | 23 |
INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old white female with no prior cardiac history. She sustained a mechanical fall with a subsequent left femoral neck fracture. She was transferred to... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal... | Cardiovascular / Pulmonary | 3 |
DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus ... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSES:,1. Hammertoe deformity, left fifth digit.,2. Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1. Hammertoe deformity, left fifth toe.,2. Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1. Arthroplasty of the left fifth digit proximal inte... | Surgery | 38 |
EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of ... | Radiology | 33 |
SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. Th... | Diets and Nutritions | 9 |
HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improve... | SOAP / Chart / Progress Notes | 35 |
SUBJECTIVE:, The patient is a 78-year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She de... | Cardiovascular / Pulmonary | 3 |
CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on... | Urology | 39 |
PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. Right breast was slightly larger than ... | Cosmetic / Plastic Surgery | 6 |
PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoul... | Surgery | 38 |
PREOPERATIVE DIAGNOSIS: , Thyroid goiter.,POSTOPERATIVE DIAGNOSIS: ,Thyroid goiter.,PROCEDURE PERFORMED: , Total thyroidectomy.,ANESTHESIA:,1. General endotracheal anesthesia.,2. 9 cc of 1% lidocaine with 1:100,000 epinephrine.,COMPLICATIONS:, None.,PATHOLOGY: , Thyroid.,INDICATIONS: ,The patient is a female with ... | Endocrinology | 13 |
REVIEW OF SYSTEMS,GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: Negative rash, negative jaundice.,HEMATOPOIETIC: Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: Negative ... | General Medicine | 15 |
CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a... | Neurology | 22 |
PREOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypert... | ENT - Otolaryngology | 11 |
HISTORY:, The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today. He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days. He denies any history of trauma. He does have incr... | Consult - History and Phy. | 5 |
CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and... | Neurology | 22 |
TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY: ,The patient is a 19... | Orthopedic | 27 |
PREOPERATIVE DIAGNOSIS:, Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to th... | Urology | 39 |
PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED: ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS: ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detect... | Obstetrics / Gynecology | 24 |
REASON FOR CONSULTATION:, Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder finding... | Hematology - Oncology | 16 |
PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: Approximately 66 minutes.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,... | Surgery | 38 |
ADMITTING DIAGNOSES,1. Vomiting, probably secondary to gastroenteritis.,2. Goldenhar syndrome.,3. Severe gastroesophageal reflux.,4. Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1. Gastroenteritis versus bowel obstruction.,2. Gastroesophageal reflux.,3. Goldenhar syndrome.,4. Anemia,... | Discharge Summary | 10 |
HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She sta... | Consult - History and Phy. | 5 |
SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracin... | SOAP / Chart / Progress Notes | 35 |
REASON FOR EXAM:,1. Angina.,2. Coronary artery disease.,INTERPRETATION: ,This is a technically acceptable study.,DIMENSIONS: ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.,FINDINGS: , Left atrium was mildly to moderately dilated. No m... | Radiology | 33 |
SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and w... | Cardiovascular / Pulmonary | 3 |
CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:, Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, ... | Cardiovascular / Pulmonary | 3 |
FINAL DIAGNOSES:,1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2. Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a... | Discharge Summary | 10 |
CC:, Progressive unsteadiness following head trauma.,HX:, A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed mecl... | Radiology | 33 |
DISCHARGE DIAGNOSES:, BRCA-2 mutation. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION: ,The chest was clear. The abdomen was nontender. Pelvic examination shows no mas... | Hematology - Oncology | 16 |
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, subseq... | Consult - History and Phy. | 5 |
PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA: ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mi... | Surgery | 38 |
EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:, Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation. There is no spondylolysis or spond... | Orthopedic | 27 |
EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identifie... | Radiology | 33 |
CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate a... | Hematology - Oncology | 16 |
PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:, IV sedation with local.,HISTORY: , Th... | Orthopedic | 27 |
SUBJECTIVE:, This 9-month-old Hispanic male comes in today for a 9-month well-child check. They are visiting from Texas until the end of April 2004. Mom says he has been doing well since last seen. He is up-to-date on his immunizations per her report. She notes that he has developed some bumps on his chest that ha... | Consult - History and Phy. | 5 |
HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum, lung, which was diagnosed approximately two years ago. There is a nodule in her lung, which was treated by excision in February of 2007 on the right side. She had spread to her kidney. She had... | Hospice - Palliative Care | 17 |
REASON FOR HOSPITALIZATION: ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distrib... | Consult - History and Phy. | 5 |
CHIEF COMPLAINT:, This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotic... | ENT - Otolaryngology | 11 |
PROCEDURE IN DETAIL:, After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder ... | Orthopedic | 27 |
PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:, The patient is a 56-year-old female. She was referred for a screening colonoscopy. The patient has bowel movements every other day. There is no blood in the stool, no abdominal pain. She has hypertension, dyslipidemia, and gastroesophageal reflux disease. She has... | Gastroenterology | 14 |
OPERATIVE PROCEDURE:,1. Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade f... | Cardiovascular / Pulmonary | 3 |
PREOPERATIVE DIAGNOSIS:, Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Pelvic endometriosis.,3. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Laparoscopy.,2. Harmonic scalpel ablation of endometriosis.,3. Lysis of adhesions.,4. Cervical dilation.,ANESTHESIA: ,General.,SPECIMEN: ,Peritoneal biopsy.,ESTI... | Surgery | 38 |
PREOPERATIVE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Anemia.,3. Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Anemia.,3. Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA: ,Gene... | Surgery | 38 |
SUBJECTIVE:, This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and she never found the top of that and wa... | General Medicine | 15 |
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 symmet... | Cosmetic / Plastic Surgery | 6 |
BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation: 18,SUMMARY:, The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately neg... | Psychiatry / Psychology | 32 |
MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:, Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan. At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview inj... | Cardiovascular / Pulmonary | 3 |
EXTERNAL EXAMINATION: , The autopsy is begun at 8:30 A.M. on May 24, 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wi... | Autopsy | 1 |
PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe with uveal prolapse OX.,PROCEDURE: ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS: , This is a XX-year-old (wo)man with a ... | Ophthalmology | 26 |
PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the ... | Pain Management | 28 |
CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other... | Neurology | 22 |
PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS: ,Fracture dislocation, C2.,OPERATION PERFORMED,1. Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2. Posterior spinal instrumentation C1-C3, using Synthes system.,3. Posterior cervical fusion C1-C3.,4. Insertion of ... | Surgery | 38 |
S: , The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:, Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, ... | Podiatry | 31 |
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