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MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal. | 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 ... | MRI T-Spine - Spinal Mets | Orthopedic | null |
Colonoscopy due to hematochezia and personal history of colonic polyps. | PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:, Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:, A History and Physical has been performed, and patient medication allergies have been reviewed. The patient's tolerance of previous anesthesia has been reviewed.... | Colonoscopy - 6 | Gastroenterology | null |
The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. | REASON FOR VISIT: ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches. She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic... | Pseudotumor Cerebri | Neurology | neurology, migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema |
Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test. | CLINICAL INDICATION: ,Normal stress test.,PROCEDURES PERFORMED:,1. Left heart cath.,2. Selective coronary angiography.,3. LV gram.,4. Right femoral arteriogram.,5. Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient ... | Heart Catheterization & Angiography - 2 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography, |
Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable. | DIAGNOSES:,1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always bee... | Bronchiolitis - Discharge Summary | Cardiovascular / Pulmonary | cardiovascular / pulmonary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs, |
Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye. | PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positio... | Phacoemulsification of Cataract | Ophthalmology | ophthalmology, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber, |
Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. | DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The... | Physical Therapy - Synovitis | Orthopedic | null |
Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast. | PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHES... | Arthrodesis | Orthopedic | orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anest... |
Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. | ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this... | CVA Consult - ER Visit | Neurology | null |
Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. | REASON FOR CATHETERIZATION:, ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Left ventriculogram.,4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncom... | Cineangiography - 2 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis, |
Pulmonary function test. Mild restrictive airflow limitation. Clinical correlation is recommended. | OBSERVATIONS: , FEV1 is 3.76, 103% predicted. FVC is 4.98, 110% predicted. Ratio is 75. FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%. DLCO is 35, 121% predicted. Residual volume is 3.04, 139% predicted. Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION... | Pulmonary Function Test - 5 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, fev1, fvc, fef, dlco, lung capacity, postbronchodilator, pulmonary function test, restrictive airflowNOTE,: 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 ... |
Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal. | REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1. Selective coronary angiography.,2. Left heart catheterization with hemodynamics.,3. LV gram with power injection.,4. Right femoral artery angiogram.,5. Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient... | Coronary Angiography | Cardiovascular / Pulmonary | null |
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma. | PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.... | Chest Tube Insertion in ER | Cardiovascular / Pulmonary | cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion, |
The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. | PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:, Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. A Gor... | Endovascular Abdominal Aortic Aneurysm Repair | Gastroenterology | gastroenterology, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries, |
A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. | HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and ... | Cardiac Consultation | Cardiovascular / Pulmonary | null |
Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. | PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Minimal.,PROCEDURE IN DETAIL: ,Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was perf... | Port-A-Cath Insertion | Cardiovascular / Pulmonary | cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire, |
She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation. | 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 fern... | Delivery Note - 9 | Obstetrics / Gynecology | 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 re... |
CT brain (post craniectomy) - RMCA stroke and SBE. | CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine culture... | CT Brain | Neurology | neurology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness, |
Echocardiographic examination. Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained. | REASON FOR EXAM:, CVA.,INDICATIONS: , CVA.,This is technically acceptable. There is some limitation related to body habitus.,DIMENSIONS: ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated... | Echocardiography | Cardiovascular / Pulmonary | cardiovascular / pulmonary, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral, |
MRI of the Cervical, Thoracic, and Lumbar Spine | INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal. At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise. At C5-C6, there were minimal diffuse disc bulge and uncovertebral ost... | MRI Spine | Orthopedic | orthopedic, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference ... |
Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. | 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... | Pulmonary Medicine Clinic Followup | Cardiovascular / Pulmonary | cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, |
1-month-old for a healthy checkup - Well child check | SUBJECTIVE:, This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.,PAST MEDI... | Well-Child Check - 8 | Pediatrics - Neonatal | null |
Gastrostomy, a 6-week-old with feeding disorder and Down syndrome. | PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to C... | Gastrostomy | Gastroenterology | gastroenterology, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy |
2-D Echocardiogram | 1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the ... | 2-D Echocardiogram - 2 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary... |
Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes. | INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tu... | Cardiac Catheterization - 2 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fractio... |
Patient referred for evaluation of her left temporal lobe epilepsy. | REASON FOR CONSULTATION: ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:, This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002. At that time, she had one... | Consult - Seizures | Neurology | null |
Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. | PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguina... | Wrist Ganglion Excision | Orthopedic | orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion |
2-D Echocardiogram | 1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the ... | 2-D Echocardiogram - 3 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary... |
Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3. | 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 ... | ORIF & Cervical Fusion | Orthopedic | orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation, |
Endoscopic release of left transverse carpal ligament. | PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: ,... | Carpal Ligament Release - 1 | Orthopedic | orthopedic, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic, |
MRI C-spine: C4-5 Transverse Myelitis. | CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when w... | MRI C-spine | Orthopedic | orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf, |
Patient complains of chest pain - possible esophageal reflux | CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; howe... | ER Report - Chest Pain | Cardiovascular / Pulmonary | null |
Cardiology office visit sample note. | HISTORY OF PRESENT ILLNESS:, This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension. Patient has severe backache secondary to disc herniation. Patient has seen an orthopedic doctor and is scheduled for surgery. Patient also came to my office for s... | Cardiology Office Visit - 3 | Cardiovascular / Pulmonary | null |
Ruptured appendicitis. | PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Ruptured appendicitis.,PROCEDURE:, Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:, This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers. The p... | Laparoscopic Appendectomy - 1 | Gastroenterology | gastroenterology, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy, |
Left third digit numbness and wrist pain. | CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pai... | MRI C3 - Cord Compression. | Orthopedic | null |
MRI Brain - Olfactory groove meningioma. | CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes... | MRI Brain - Meningioma (Olfactory) | Neurology | neurology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual, |
Holter monitor report. Predominant rhythm is sinus. Triplet maximum rate of 178 beats per minute noted. | INDICATIONS: , Predominant rhythm is sinus. Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute. Minimum heart rate of 50 beats per minute.,640 ventricular ectopic isolated beats noted. Rare isolated APCs and supraventricular couplets.,One supraventricular triplet reported.,T... | Holter Monitor Report - 1 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, holter monitor, heart rate, supraventricular, triplet, heart, beatsNOTE,: 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 m... |
A 27-year-old female with a size and date discrepancy. | GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM. Fetal Lie: Longitudinal. Fetal Presentation: Cephalic. Placenta: Anterior Grade I. Uterus: Normal. Cervix: Closed. Adnexa: Not seen. Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 3... | Ultrasound OB - 7 | Obstetrics / Gynecology | null |
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. | REASON FOR CONSULTATION:, Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has r... | Metastatic Ovarian Cancer - Consult | Obstetrics / Gynecology | null |
Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure. | PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PRO... | Ventriculostomy Placement | Neurosurgery | neurosurgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular |
Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain. | PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERAT... | Craniotomy - Burr Hole | Neurosurgery | neurosurgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space |
A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. | 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 mo... | Infantile Spasms | Pediatrics - Neonatal | null |
Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. | PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:, Breast mass, left.,PROCEDURE:, Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Pre... | Breast Mass Excision - 2 | Obstetrics / Gynecology | obstetrics / gynecology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen, |
1-month-old for a healthy checkup - Well child check | SUBJECTIVE:, This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.,PAST MEDI... | Well-Child Check - 7 | Pediatrics - Neonatal | null |
Status post colonoscopy. After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation. | CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during th... | Blood per Rectum | Gastroenterology | null |
Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested. | 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... | CT Lumbar Spine | Orthopedic | orthopedic, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, |
Stress test with Bruce protocol due to chest pain. | PROTOCOL:, Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:, Chest pain.,PROCEDURE AND INTERPRETATION: ,1. Baseline heart rate: 67.,2. Baseline blood pressure: 150/86.,3. Total time: 6 minute 51 seconds.,4. METs: 10.1.,5. Peak heart rate: 140.,6. Percent of maximum-predicted heart rate: 90.,7. Peak ... | Stress Test Bruce Protocol | Radiology | null |
Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus. | PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:, Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tis... | Pituitary Adenomectomy | Neurosurgery | null |
Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA. | PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Pe... | Cardiac Catheterization - 4 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arterioto... |
Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time whe... | REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episod... | Lightheaded & Dizziness | Cardiovascular / Pulmonary | null |
Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain. | PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Less than... | Anterior Lumbar Fusion | Neurosurgery | neurosurgery, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion, |
Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. | CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted... | Hypergranulation - Consult | Orthopedic | null |
Psychosocial Evaluation of patient before kidney transplant. | HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is... | Psychosocial Eval for Kidney Transplant | Psychiatry / Psychology | null |
Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated. | POSTOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy.,OPERATION PERFORMED: Adenotonsillectomy.,ANESTHESIA: General endotracheal.,INDICATIONS: The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE: The pat... | Adenotonsillectomy - 2 | ENT - Otolaryngology | ent - otolaryngology, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: 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.The... |
Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain. | 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. | Radiologic Exam - Spine | Orthopedic | orthopedic, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebr... |
Multiple stent placements with Impella circulatory assist device. | PROCEDURE PERFORMED:,1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtai... | Multiple Stent Placements | Cardiovascular / Pulmonary | cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coro... |
Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma. | PREOPERATIVE DIAGNOSIS: ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneur... | Pterional Craniotomy | Neurosurgery | neurosurgery, hemorrhage, arteriovenous malformation, aneurysm, pterional craniotomy, bone flap, bipolar coagulation, arteriovenous, pterional, malformation, hematoma, intracerebral, |
Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture. | PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female ... | Hemiarthroplasty - Austin-Moore Bipolar | Orthopedic | orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral, |
Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right. | PREOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,PROCEDURES:, ,1. Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2. Placement of antibiotic-impregnated beads.,ANESTHESIA:, Gene... | Antibiotic-Impregnated Beads Placement | Orthopedic | orthopedic, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic |
Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy. | PREOPERATIVE DIAGNOSES:,1. Medial meniscal tear, posterior horn of left knee.,2. Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3. Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1. Carpal tun... | Arthroscopy Shoulder/Knee | Orthopedic | null |
Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion. | PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.... | Chest Tube Insertion | Cardiovascular / Pulmonary | cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma |
Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left. | PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underw... | Thoracotomy & Pleurectomy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest |
The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. | SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was s... | SOAP - Shortness of Breath | Cardiovascular / Pulmonary | cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr, |
Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency. | 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,... | Goldenhar Syndrome - Discharge Summary | Pediatrics - Neonatal | null |
Duplex ultrasound of legs | 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 ... | Duplex Ultrasound - Legs | Cardiovascular / Pulmonary | cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins, |
Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions. | PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003. She is blood type AB -ve with antibody screen negative and is also r... | Spontaneous Vaginal Delivery | Obstetrics / Gynecology | obstetrics / gynecology, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal, |
Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage. | PREOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical steno... | Anterior Cervical Discectomy & Interbody Fusion - 2 | Neurosurgery | neurosurgery, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy, |
Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema. | PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDI... | Tracheostomy Change | Cardiovascular / Pulmonary | cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator |
Patient had some cold symptoms, was treated as bronchitis with antibiotics. | DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY... | Discharge Summary | Cardiovascular / Pulmonary | cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, |
Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis. | PREOPERATIVE DIAGNOSIS:, Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requir... | Bronchoscopy & Bronchoalveolar Lavage | Cardiovascular / Pulmonary | cardiovascular / pulmonary, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis |
Primary low transverse cervical cesarean section. Intrauterine pregnancy at 38 weeks and malpresentation. A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g. No nuchal cord. No meconium. Normal uterus, fallopian tubes, and ovaries. | PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 38 weeks.,2. Malpresentation.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 38 weeks.,2. Malpresentation.,3. Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.... | Low-Transverse C-Section - 5 | Obstetrics / Gynecology | obstetrics / gynecology, low transverse cervical cesarean section, cesarean section, pregnancy, neonate, metzenbaum scissors, intrauterine pregnancy, rectus fascia, rectus muscle, intrauterine, peritoneum, malpresentation, transverse, astramorph, |
A 5-month-old boy brought by his parents because of 2 days of cough. | CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and h... | A 5-month-old boy with cough | Pediatrics - Neonatal | null |
Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain. | CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe.... | Sinus problems - Consult | ENT - Otolaryngology | null |
Neurologic examination sample. | NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of ny... | Neurologic Examination | Neurology | neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE |
Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube. | 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... | Tracheostomy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy,... |
Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus. | ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:, This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded... | Anterior Cervical Discectomy - 2 | Neurosurgery | neurosurgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE |
Patient with immune thrombocytopenia | SUBJECTIVE: , I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematolo... | Thrombocytopenia - SOAP Note | Hematology - Oncology | hematology - oncology, platelets, platelet count, thrombocytopenia, prednisone, |
Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis. | PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL ... | Hysterectomy & Salpingoophorectomy | Obstetrics / Gynecology | null |
Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye. | CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's ... | Clear Corneal Temporal Incision | Ophthalmology | ophthalmology, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not... |
Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy. | 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 exc... | Laryngectomy & Thyroid Lobectomy | ENT - Otolaryngology | ent - otolaryngology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage |
The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma. | CHIEF COMPLAINT: , Left breast cancer.,HISTORY:, The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferom... | Consult - Breast Cancer - 2 | Hematology - Oncology | null |
Small internal hemorrhoids and Ileal colonic anastomosis. | PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:, The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted app... | Colonoscopy with Biopsy - 2 | Gastroenterology | gastroenterology, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy |
14 years old complaining about severe ear pain - Chronic otitis media. | PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibioti... | Ear pain - Pediatric Consult | Pediatrics - Neonatal | null |
Patient comes for discussion of a screening colonoscopy. | HISTORY:, A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been a... | Consult - Screening Colonoscopy | Gastroenterology | gastroenterology, screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy, |
Endovascular Brachytherapy (EBT) | ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determ... | Endovascular Brachytherapy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of ... |
Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor. | PROCEDURES:,1. Right frontal craniotomy with resection of right medial frontal brain tumor.,2. Stereotactic image-guided neuronavigation for resection of tumor.,3. Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE: ,The p... | Craniotomy & Neuronavigation | Neurosurgery | neurosurgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection, |
Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia. | PROBLEMS LIST:,1. Type 1 diabetes mellitus, insulin pump requiring.,2. Chronic kidney disease, stage III.,3. Sweet syndrome.,4. Hypertension.,5. Dyslipidemia.,6. Osteoporosis.,7. Anemia.,8. A 25-hydroxy-vitamin D deficiency.,9. Peripheral neuropathy manifested by insensate feet.,10. Hypothyroidism.,11. Diabe... | Chronic Kidney Disease Followup - 2 | Nephrology | null |
Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared. | ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture ... | Hip Fracture - Rehab Consult | Orthopedic | null |
A 2-month-old female with 1-week history of congestion and fever x2 days. | CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid b... | Congestion & Fever - 2-month-old | Pediatrics - Neonatal | null |
MRI - Right temporal lobe astrocytoma. | CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He... | Astrocytoma | Neurology | neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal, |
H&P for a female with Angina pectoris. | CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Con... | H&P - Cardio (Angina) | Cardiovascular / Pulmonary | null |
Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft. | PREOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with... | Laminectomy & Foraminotomy & Cervical Fusion | Orthopedic | null |
Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx. | PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputa... | Symes Amputation - Hallux | Hematology - Oncology | hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux |
Laparoscopy with ablation of endometriosis. Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid ... | PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uteros... | Laparoscopy - 4 | Obstetrics / Gynecology | obstetrics / gynecology, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation |
Bilateral endoscopic proximal shunt revision and a distal shunt revision. | TITLE OF OPERATION:, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:, Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:, Coaptation of ventricles against proximal end ... | Shunt Revision | Neurosurgery | neurosurgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal |
Holter monitoring - For bradycardia and dizziness. | INDICATION: , Bradycardia and dizziness.,COMMENTS:,1. The patient was monitored for 24 hours.,2. The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3. There were occasional pr... | Holter Monitoring | Cardiovascular / Pulmonary | cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring, |
MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH) | CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He "knew what he wanted to say, but could not say it.",His speech was slurred and he found it difficult to control his tongue. Examination at that time ... | MRI Brain - Progressive Aphasia | Radiology | null |
Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right ... | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,POS... | Bunionectomy & Arthrodesis | Orthopedic | null |
Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention. | DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painf... | Physical Therapy - Back Pain | Orthopedic | null |
Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. | ADMISSION DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had s... | Pneumonia - Discharge Summary | Cardiovascular / Pulmonary | cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, |
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