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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1400
}
|
CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a "flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found "passed out" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66. HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1401
}
|
PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure. Oxygenation was given. The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE: ,The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine. The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***. Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves. Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue. After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was used throughout the procedure.,COMPLICATIONS:, None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.orthopedic, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1402
}
|
PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:, Cauterization of peri and intra-anal condylomas.,ANESTHESIA: ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week.surgery, intra-anal, perianal, acuminata, cauterization, condyloma, anal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1403
}
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PROCEDURE:, Cervical epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the sitting position. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between C7-T1 ________. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted. After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected. Neosporin and band-aid were applied over the site. The patient discharged to recovery room in stable condition.pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, injection,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1404
}
|
PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY: ,Pending.,TITLE OF PROCEDURES: ,1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.surgery, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1405
}
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PREOPERATIVE DIAGNOSIS:, Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1. Ligation and stripping of left greater saphenous vein to the level of the knee.,2. Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:, None.,BRIEF HISTORY:, This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.,OPERATIVE FINDINGS:, The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE: ,The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.surgery, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1406
}
|
PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. Vital signs were monitored by blood pressure, heart rate, and oxygen saturation. Supplemental O2 given. Specifics of the procedure discussed. The procedure was discussed with father and mother as the patient is mentally challenged. He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year. He went to the emergency department yesterday with beef jerky.,All of this reviewed. The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP. He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency. He has not yet undergone significant workup. He has not yet had an endoscopy or barium study performed. He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture. The patient does not smoke, does not drink. He is living with his parents. Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress. Vital signs monitored in the endoscopy suite. Lungs clear. Cardiac exam showed regular rhythm. Abdomen obese but soft. Extremity exam showed large hands. He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother. Risks, benefits, and alternatives discussed. Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed. The potential need for a barium swallow, modified barium swallow, and similar discussed. All questions answered. At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture. He may have reflux symptoms, without complaining of heartburn. He may benefit from a trial of PPI. All of this reviewed. All questions answered.,gastroenterology, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1407
}
|
PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.surgery, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1408
}
|
CHIEF COMPLAINT:, Dental pain.,HISTORY OF PRESENT ILLNESS:, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease. She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable. Has not noted any fever or chills. However she, as mentioned, does note the dental discomfort with increasing swelling and pain. Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile, has stable and normal vital signs. The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain. HEENT: Unremarkable. I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region. There is no neck adenopathy. Oral mucosa is moist and well hydrated. Dentition looks to be in reasonable condition. However, she definitely is tender to percussion on the left lower first premolar. I do not see any huge cavity or anything like that. No real significant gingival swelling and there is no drainage noted. None of the teeth are tender to percussion.,PROCEDURE:, Dental nerve block. Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia. I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN: ,The patient needs to follow up with the dentist for definitive treatment and care. She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics. However, outpatient followup should be adequate. She is discharged in stable condition.dentistry, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1409
}
|
EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.,FINDINGS: ,There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.,IMPRESSION: ,No acute intracranial process.radiology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1410
}
|
HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed some mild inferior wall scar and ejection fraction was well preserved. He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:, Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY: ,Father died at the age of 84. He had a prior history of cancer of the lung and ischemic cardiac disease. Mother died in her 80s from congestive heart failure. He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY: ,Quit smoking in 1996. He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine: He has hypercholesterolemia treated with diet and medication. He reports that he did lose 10 pounds this year.,Neurologic: Denies any TIA symptoms.,Genitourinary: He has occasional nocturia. Denies any difficulty emptying his bladder.,Gastrointestinal: He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 225 pounds. Blood pressure: 130/82. Pulse: 83. Temperature: 96.4 degrees.,General Appearance: He is a middle-aged man who is not in any acute distress.,HEENT: Mouth: The posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1, S2, without gallops or rubs.,Abdomen: Without tenderness or masses.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Ischemic cardiac disease. This remains stable. He will continue on the same medication. He reports he has had some laboratory studies today.,2. Hypercholesterolemia. He will continue on the same medication.,3. Facial tic. We also discussed having difficulty with the facial tic at the left orbital region. This occurs mainly when he is under stress. He has apparently had numerous studies in the past and has seen several doctors in Wichita about this. At one time was being considered for some type of operation. His description, however, suggests that they were considering an operation for tic douloureux. He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close. Repeat neurology evaluation was advised. He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4. Immunization. Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment. We will have this discussed with him further when his laboratory results are back.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1411
}
|
PREOPERATIVE DIAGNOSIS:, Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:, Atrophic vaginitis.,PROCEDURE: ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position. The patient then had flexible scope placed through the urethral meatus and into the bladder. Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body. Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.surgery, urge incontinence, frequency, overactive bladder, vesicare, flexible cystoscopy, bladder infections, atrophic vaginitis, incontinence, cystoscopy, vaginitis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1412
}
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We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d. This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. She also is on an ACE inhibitor.,So her discharge meds are as follows:,1. Coreg 6.25 mg b.i.d.,2. Simvastatin 40 mg nightly.,3. Lisinopril 5 mg b.i.d.,4. Protonix 40 mg a.m.,5. Aspirin 160 mg a day.,6. Lasix 20 mg b.i.d.,7. Spiriva puff daily.,8. Albuterol p.r.n. q.i.d.,9. Advair 500/50 puff b.i.d.,10. Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks. She is to follow up with Dr. X before that.general medicine, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1413
}
|
EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.,radiology, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1414
}
|
PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descending, rectosigmoid and rectum. Retroflexion noted no abnormality of the internal ring. No hemorrhoids were noted. Withdrawal from the patient terminated the procedure.surgery, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1415
}
|
HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here. Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1. Atenolol 25 mg once a day.,2. Altace 2.5 mg once a day.,3. Zocor 20 mg once a day.,4. Flecainide 200 in the morning and 100 in the evening.,5. Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE. HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well. The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. No use of illicit drugs. He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:, Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null. The patient expressed understanding of this risk, benefit, and alternative analysis. I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE: ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. The patient did actively participate in this time-out procedure. After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22. We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed. I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself. Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1416
}
|
The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS: Proximal and mid esophagus were without abnormalities.,STOMACH: Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM: Normal.surgery, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1417
}
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CHIEF COMPLAINT:, Cut on foot.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints.,PAST MEDICAL HISTORY:, Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. Oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well-nourished, well-developed, the patient appears to be healthy. The patient is calm and comfortable in no acute distress and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:, The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1. A 4-MM LACERATION TO THE RIGHT FOOT.,2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.emergency room reports, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1418
}
|
CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.,SPECIMEN:,A. Lung, wedge biopsy right lower lobe,B. Lung, resection right upper lobe,C. Lymph node, biopsy level 2 and 4,D. Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.,C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT: ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1419
}
|
PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1. Abscess secondary to retained foreign body.,2. Incisional hernia.,PROCEDURES,1. Excision of abscess, removal of foreign body.,2. Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma. The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill. He presented to my office and I recommended that he undergo exploration of this area and removal. The procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,FINDINGS:, The patient was found upon excision of the cyst that it contained a large Prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,DESCRIPTION OF PROCEDURE: , The patient was identified, then taken into the operating room, where after induction of an LMA anesthetic, his abdomen was prepped with Betadine solution and draped in sterile fashion. The puncta of the wound lesion was infiltrated with methylene blue and peroxide. The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base. In doing so, we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia. The cyst was removed in its entirety, divided from the omentum using a Metzenbaum and tying with 2-0 silk ties. The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures. The wound was then irrigated and closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular and Steri-Strips. Patient tolerated the procedure well. Dressings were applied and he was taken to recovery room in stable condition.gastroenterology, sebaceous cyst, prolene suture, incisional hernia, incisional, abscess, hernia, abdomen, omentum, excision, cyst,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1420
}
|
CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY: ,Noncontributory.,MEDICATIONS: ,None.,ALLERGIES: ,None.,PHYSICAL EXAMINATION: , GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine.,FINAL DIAGNOSIS:,1. First-degree and second-degree burns, right arm secondary to hot oil spill.,2. Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.consult - history and phy., burn, workers' compensation industrial injury, workers' compensation, degree
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1421
}
|
PREOPERATIVE DIAGNOSIS:, Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:, After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1422
}
|
The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.office notes, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1423
}
|
CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1424
}
|
3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. Radiographs are taken and these films are approved by the physician. Appropriate marks are placed on the patient's skin or on the immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table. Scans are performed through the targeted area. The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images. The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. Appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.hematology - oncology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1425
}
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IDENTIFYING DATA:, The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:, The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:, The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D. Historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works. He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past, probably in high school, the patient recalled being more figidity than now. He tensed to feel anxious. Sleep has been highly variable. He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. Appetite has been good. He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed. His energy level is "better now," but this was very problematic in the past. He has problems with motivation. In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:, The patient has never been hospitalized for psychiatric purposes. His only treatment has been at this facility. He tried Adderall for a time, and it helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the other half of the tablet in the afternoon.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1426
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On review of systems, the patient admits to hypertension and occasional heartburn. She undergoes mammograms every six months, which have been negative for malignancy. She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure. She has had negative PPD.,PAST MEDICAL HISTORY:, Hypertension.,PAST SURGICAL HISTORY:, Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore. She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation: She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:, Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP: 133/72nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1427
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S:, The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:, Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings are temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, # 1 right and #1 left.,A:,1. Onychomycosis present, #1 right and #1 left.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,P: , Nails #1 right and #1 left were debrided for length and thickness. All the nails were reduced. The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails.podiatry, length and thickness, mycotic nails, classic findings, onychomycosis, nails,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1428
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XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,hematology - oncology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1429
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PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:, Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1. Severe duodenitis.,2. Gastroesophageal junction small ulceration seen.,3. No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position. Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction. Advanced into the upper part of the stomach into the antrum. The duodenum showed extreme duodenitis and the scope was then brought back. Retroflexion was performed, which was normal. Scope was then brought back slowly. Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.surgery, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1430
}
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CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1431
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TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06. This was complicated by posterior capsule rupture. An intraocular lens implant was not attempted. He developed corneal edema and a preretinal hemorrhage. He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,POSTOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,ANESTHESIA: , General.,SPECIMEN: ,1. Donor corneal swab sent to Microbiology.,2. Donor corneal scar rim sent to Eye Pathology.,3. The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT: ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered. The patient was brought to the preoperative holding area, where the operative left eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced. The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. A lid speculum was placed. The posterior segment infusion was placed by the vitreoretinal service. Peritomy was performed at the 3 and 9 o'clock limbal positions. A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. The cornea was then measured and was found to accommodate a 7.5-mm trephine. The center of the cornea was marked. The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface. This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. Corneoscleral scissors were then used to excise completely the central cornea. The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. This was done without difficulty. At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. The 9-0 Prolene sutures double armed were then placed on each lens haptic loop. The keratoprosthesis was removed. Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. Wet-field cautery also was performed to achieve hemostasis. The leading hepatic sutures were then passed through the bed of the scleral flap. These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. The trailing hepatic was then placed into the posterior segment of the eye as well. The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. These were tied securely into position with the IOL nicely centered. At this point, the donor cornea punched at 8.25 mm was then brought into the field. This was secured with four cardinal sutures. The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. The knot was secured and buried after adequate tension was adjusted. The corneal graft was watertight. Attention was then turned back to the IOL sutures, which were locked into position. The ends were trimmed. The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. No complications were noted. The attending surgeon, Dr. X, performed the entire procedure. No complications of the procedure were noted. The intraocular lens was selected from preoperative calculations. No qualified resident was available to assist.surgery, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1432
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PREOPERATIVE DIAGNOSIS: ,Lateral epicondylitis.surgery, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1433
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REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation. An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care. He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred. He is currently on dialysis due to end-stage renal disease and has a tracheostomy. He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet. He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes. He currently rates his pain as 7 out of 10. He denies a depressed mood or anxiety and states that he knows he is getting better. He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl. He has PEG for tube feeding. He has weakness on left side of his body as well as both legs since his MI. He has been switched from fentanyl IV q.2h. to the fentanyl patch today. He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007. He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions. His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1. DVT in December 2005.,2. Three MI's (1996, 2005, and 2006).,3. Diabetes for 5 years.,4. Coronary artery disease for 10 years.,PAST SURGERIES:,1. Appendectomy as a child.,2. CABG x3, November 2005.,3. Sternal rewiring, December 2005.,MEDICATIONS:,1. Restoril 7.5 mg p.o. at bedtime p.r.n.,2. Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3. Aspirin 81 mg p.o. daily.,4. Bisacodyl suppository 10 mg per rectum daily.,5. Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6. Esomeprazole 40 mg IV q.12h.,7. Fentanyl patch 25 mcg per hour.,8. Transderm patch every 72 hours.,9. Heparin IV.,10. Lactulose 30 mL p.o. daily p.r.n. constipation.,11. Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12. Seroquel 12 mg p.o. at bedtime.,13. Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14. Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15. Bactrim suspension p.o. daily.,16. Insulin medium dose sliding scale.,17. Albumin 25% IV p.r.n. hemodialysis.,18. Ipratropium solution for nebulizer.,ALLERGIES:, No known drug allergies.,PAST PSYCHIATRIC HISTORY:, The patient denies any past psychiatric problems. No medications. He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:, He lives with his wife in New Jersey. He has 2 children. One son in Texas City and 1 daughter in Florida. He is a master mechanic for a trucking company since 1968. He retired in the May 2006. The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996. He occasionally has a beer, but denies any continuous use of alcohol. He denies any illicit drug use.,FAMILY HISTORY:, Both parents died with myocardial infarctions. He has 2 sisters and a brother with diabetes mellitus and coronary artery disease. He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:, The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding. The patient's appearance was appropriate with fair-to-good grooming and hygiene. He had little-to-no psychomotor activity secondary to weakness post MI. He had good eye contact. His speech was of decreased rate volume and flexion secondary to tracheostomy. The patient was cooperative. He described his mood is not good in congruent stable and appropriate affect with decreased range. His thought process is logical and goal directed. His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation. He denied any perceptional disturbances including any auditory or visual hallucinations. He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I: Pain with physical symptoms and possibly psychological symptoms.,AXIS II: Deferred.,AXIS III: See above.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1434
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PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:, Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma. The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination. Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring. There was no palpable lymphadenopathy in either inguinal node region. There were no other nodules, ulcerations, or other lesions. At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:, The patient was brought to the Operating Room with an IV in place. She was placed in the low anterior lithotomy position after adequate anesthesia had been induced. Examination under anesthesia was performed with findings as noted, after which she was prepped and draped. The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament. Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary. The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis. The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial. The cribriform fascia was isolated and dissected with preservation of the femoral nerve. The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments. The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally. The saphenous vessels were identified and preserved bilaterally. The inferior margin of the specimen was ligated, divided, and removed. Inguinal node sites were irrigated and excellent hemostasis was noted. Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches. The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen. A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins. The medial margin extended into the vagina and was approximately 5-8 mm. The skin was incised and underlying adipose tissue was divided with electrocautery. Vascular bundles were isolated, divided, and ligated. After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site. Margins were submitted on the right posterior, middle, and anterior vaginal side walls. After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture. The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.obstetrics / gynecology, squamous cell carcinoma, vulvectomy, radical vulvectomy, bilateral inguinal lymphadenectomy, hymeneal ring, camper's fascia, carcinoma of the vulva, inguinal lymphadenectomy, lymph nodes, inguinal, vulva, squamous, carcinoma, radical, lymphadenectomy, fascia, vaginal, nodes
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1435
}
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PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:, Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair. The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right. The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced. The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:, After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion. An infraumbilical incision was made with a #15 Bard-Parker scalpel. The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty. Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg. Next, the Veress was removed and #10 bladed trocar was inserted without difficulty. The 30-degree camera laparoscope was then inserted and the abdomen was explored. There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible. Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus. Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization. A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization. Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral. The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty. Dissection was carried out, freeing up the hernia sac from the peritoneum. This was done without difficulty reducing the hernia in its entirety. Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract. The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples. This was done without difficulty. All three ports were removed under direct visualization. No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle. Skin was closed with running subcuticular #4-0 undyed Vicryl. Steri-Strips and sterile dressings were applied. Attention was next made to carrying out the circumcision. The foreskin was retracted back over the penis head. The desired amount of removing foreskin was marked out with a skin marker. The foreskin was then put on tension using a clamp to protect the penis head. A #15 blade scalpel was used to remove the foreskin and sending off as specimen. This was done without difficulty. Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially. This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing. The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.urology, herniorrhaphy with mesh, laparoscopic, blunt dissector, inguinal herniorrhaphy, inguinal hernia, hernia, inguinal, peritoneum, circumcision, phimosis, foreskin
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1436
}
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PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy.surgery, retinal periphery, conjunctival peritomy, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1437
}
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PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:, Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS: ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis. She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief. She is presenting today for release of the first dorsal extensor compartment. She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics. She was taken to the operating suite under the auspices of Anesthesiology. She was given a left upper extremity bier block. Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution. Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment. Dissection was carried down through the dermis into the subcutaneous tissue. The dorsal radial sensory branches were kept out of harm's way. They were retracted gently to the ulnar side of the wrist. The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally. Both the extensor pollices brevis and abductor pollices longus tendons were identified. There was no pathology noted within the first dorsal extensor compartment. The wound was irrigated. Hemostasis was obtained with bipolar cautery. The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch. Sterile occlusive dressing was applied along with the thumb spica splint. The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition.surgery, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1438
}
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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 breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1439
}
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PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: ,Medial right inferior helix.,PREOP SIZE:, 1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.surgery, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1440
}
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SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.,HEART: Regular rhythm and rate.,ABDOMEN: Soft, less tender.,LABORATORY DATA:, Her white count continues to come down. Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000. We have ordered type and cross for 2 units of packed red blood cells. If it drops below 25, she will receive a transfusion. Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:, She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.gastroenterology, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1441
}
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CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glans penis. Next, incision line was marked circumferentially on the outer skin 3 mm below the corona. The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia. Next, the foreskin was retracted. Another circumferential incision was made 3 mm proximal to the corona. The intervening foreskin was excised. Meticulous hemostasis was obtained with electrocautery. Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock. The stitches were placed equal distance among these to reapproximate all the skin edges. Next, good cosmetic result was noted with no bleeding at the end of the procedure. Vaseline gauze, Telfa, and Elastoplast dressing was applied. The stay-stitch was removed and pressure held until bleeding stopped. The patient tolerated the procedure well and was returned to the recovery room in stable condition.urology, circumcision, elastoplast, meticulous hemostasis, telfa, vaseline gauze, circumferential incision, corona, cosmetic result, endotracheal anesthesia, foreskin, glans penis, hemostasis, stay stitch, circumferentially, stitchNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1442
}
|
PREOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE: ,The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition.cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1443
}
|
PREOPERATIVE DIAGNOSES,1. Postoperative wound infection.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1. Postoperative wound infection. There was an intraperitoneal foreign body.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,PROCEDURES,1. Incision and drainage (I&D) of gluteal abscess.,2. Removal of pigtail catheter.,3. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed. Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion. The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward. I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism. It came out without any difficulty. Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion. My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision. I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen. Very carefully, I started dividing the fascia. Of course, there were several small bowel loops adhered to the area. The dissection was quite tedious for a while. Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract. I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia. There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination. Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula. The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS. The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied. A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area. The patient tolerated the procedure well. Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating.surgery, intraperitoneal pigtail catheter, postoperative wound infection, foreign body, intraperitoneal, exploratory laparotomy, enterocutaneous fistula, wound infection, sinus tract, gluteal abscess, pigtail catheter, i&d, abscess, laparotomy, fascia, pigtail, catheter, gluteal, incision, foreign
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1444
}
|
PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:, Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:, One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE: ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally __________ suction. The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point, the procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transported to PACU in good condition.surgery, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1445
}
|
OPERATIVE NOTE: ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner. The penis was inspected. The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove. This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures. The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis. An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora. The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie. Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin. There was good viability of the skin. The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin. This was removed and hemostasis was obtained with a Bovie. 0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut. At the conclusion of the procedure, Vaseline gauze was wrapped around the penis. There was good hemostasis and the patient was sent to the recovery room in stable condition.urology, penis, meatus, urethral groove, corpora, glans, meatoplasty, bovie, chromic, catgut, hemostasisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1446
}
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PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS: ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a dual-chamber pacemaker.,2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Versed 2.5 mg.,2. Fentanyl 150 mcg.,3. Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2. Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3. Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Completion of the course of antibiotics.,4. Home dismissal instructions provided in written format.,5. Device interrogation in the morning.,6. Wound check in 7 to 10 days.,7. Enrollment in device clinic.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 1447
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ASH SPLIT VENOUS PORT,PROCEDURE DETAILS: ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion. Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter. The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle. Under fluoroscopic control, a J-wire was advanced into the right atrium. The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel. A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision. The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control. The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system. The sheath was peeled away, leaving the catheter into position. Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position. The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture "wings.",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied. Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.cardiovascular / pulmonary, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1448
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PROCEDURE:, Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. The patient received topical lidocaine by nebulization. The flexible fiberoptic bronchoscope was introduced orally. The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions. I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe. I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies. Followup fluoroscopy was negative for pneumothorax. I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions. I performed a bronchial washing after the biopsies in the right upper lobe. I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area. All of these samples were sent for histology and cytology respectively. Estimated blood loss was approximately 5 cc. Good hemostasis was achieved. The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well. Her ASA score was 2.surgery, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
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DIAGNOSIS:, Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:, General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two. He tolerated the procedure well. A sterile dressing was applied. He was awakened and transferred to the recovery room in stable condition.surgery, scrotal incision, right vas, bleeding, anesthesia, vasectomy
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{
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"dataset_name": "medical-transcription-40",
"id": 1450
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EXAM: ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:, Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis, ureteral dilatation. There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths. The bladder is nearly completely decompressed. There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,The appendix is normal. There is no evidence for a pericolonic inflammatory process or small bowel obstruction.,Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths. There is no pelvic free fluid or adenopathy.,Lung bases appear clear. Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. No renal stone or evidence of obstruction. Stable appearing pelvic calcifications likely indicate phleboliths.,2. Normal appendix.radiology, pericolonic inflammatory process, phleboliths, renal stone protocol, ct kub, ct abdomen, ureteral dilatation, free fluid, renal stone, noncontrast, kub, adenopathy, abdomen, ct, renal, stone, obstruction, pelvis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
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CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.orthopedic, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,
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CHIEF COMPLAINT:, Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:, The patient is a 21-year-old Hispanic female. She comes in today with her boyfriend. The patient speaks English fairly well, but her primary language is Spanish. Her boyfriend does help to make sure that she understands what we are talking about. The patient seems to understand our conversation fairly well. She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m. She was pushing a cart and mashed her thumb between the cart and the wall. This was at the finishing room in Norcraft. She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th. She has swelling in her thumb. It hurt only if it is pushed on. It was the distal end of her thumb that was mashed. She has not noticed any numbness or tingling or weakness. She has not sought any treatment for this, is not taking any pain medications. She did try soaking it in warm salt water and did not notice any improvement.,MEDICATIONS: , None.,ALLERGIES: , None.,PAST MEDICAL HISTORY:, Possible history of chicken pox, otherwise no other medical illnesses. She has never had any surgery.,FAMILY HISTORY: , Parents and two siblings are healthy. She has had no children.,SOCIAL HISTORY:, The patient is single. She lives with her boyfriend and his father. She works at Norcraft. She wears seatbelt 30% of the time. I encouraged her to use them all of the time. She is a nonsmoker, nondrinker.,VACCINATIONS: , She thinks she got a tetanus vaccine in childhood, but does not know for sure. She does not think she has had a tetanus booster recently.,REVIEW OF SYSTEMS:,Constitutional: No fevers, chills, or sweats.,Neurologic: She has had no numbness, tingling, or weakness.,Musculoskeletal: As above in HPI. No other difficulties.,PHYSICAL EXAMINATION:,General: This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress.,Vital Signs: Weight: 121.4. Blood pressure: 106/78. Pulse: 64. Respirations: 20. Temperature: 96.,Extremities: Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed. The nail bed is pushed up. I can see hematoma below the nail bed, although it does appear to be intact. She has some blue fingernail polish on her nail also, but that is starting to come off. She is able to bend her thumb normally at the DIP joint. She has no discomfort doing that. Sensation is intact over the entire thumb. She has normal capillary refill. There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed. I am not feeling any fluctuance. I do not think it is a collection of pus. There is no drainage. She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all. It looks like there may be some mild cellulitis at the site of her injury.,LABORATORY:, X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body.,ASSESSMENT:, Blunt trauma to the distal right thumb without fracture. I think there is some mild cellulitis developing there.,PLAN:,1. We will give a tetanus diphtheria booster.,2. We will start Keflex 500 mg one p.o. q.i.d. x 7 days. I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb. I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time. If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call. Otherwise I will be seeing her back on Monday.nan
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PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:, Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE: ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA: ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED: ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS: ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS: ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION: ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang. It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction. Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION: ,The patient was taken to the operative room. Surgical consent, operative site, and patient identification were verified. Dr. X and Dr. Y both agreed upon the procedures in advance. Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position. Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French. The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis. I was able to locate the ureteral orifice bilaterally, although no urine coming from the right. We then placed a 4-French ureteral catheter into the ureter as far as we could go. An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter. A retrograde was performed, and it was found that there was a narrowed band across the two. Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all. Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder. Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll. He was then sterilely prepped and draped. Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised. Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________. At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia. Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum. Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this. The tissue was markedly inflamed and had significant adhesions noted. The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction. Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter. Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture. Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder. Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed. Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair. Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect. The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage. Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position. This opening was at least 1.5 cm wide. Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health. Electrocautery was used on the base. There was no bleeding, however, and the tissue was quite soft. Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures. Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers. Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively. A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped. Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder. The Foley catheter was then taped to his leg. A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.urology, cystoscopy, pyeloureteroscopy, ureteropelvic junction obstruction, pseudomonas pyelonephritis, renal insufficiency, fortaz, ureteropelvic junction repair, nephrostomy tube, renal biopsy, renal pelvis, foley catheter, ureteropelvic junction, renal, ureteropelvic,
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REASON FOR VISIT:, Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3. Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds. Abdomen: Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:, The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks. Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection. Questions regarding hospital course and recovery were addressed. We will continue on the Medifast diet until the time of surgery and cleared for surgery.bariatrics, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,
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{
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TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,ANESTHESIA:, General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:, 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was then inflated. Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon. The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the periosteum of the first left metatarsal. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft. Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact. The screws were sent to pathology for examination. The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification. The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding. The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy. Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished. The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft. Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent. The area was flushed copiously flushed with saline. The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material. All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time. The left ankle tourniquet was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels. The patient was given specific instructions and education on how to continue caring for his left foot surgery. The patient was also given pain medications, instructions on how to control his postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws,
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CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis. He reports he experienced a single episode of his vision decreasing "like it was compressed from the top down with a black sheet coming down". The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car. He was able to pull the car over to the side of the road safely. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale and ashen during the episode. He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable. It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker. He has had no further similar events. He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis. The question has arisen as to whether he should have a CT myelogram to further evaluate this process. He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness. He is extremely active and plays tennis at least three times a week. He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain. He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative. A copy is in his clinic chart.,PAST MEDICAL HISTORY: ,As above. He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, He is retired from the social security administration x 20 years. He travels a lot and is extremely active. He does not smoke. He consumes alcohol socially only. He does not use illicit drugs. He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago. He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs: BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds. He denies any pain.,General: This is a pleasant white male in no acute distress.,HEENT: He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness.,Neck: Supple.,Chest: Clear to auscultation.,Heart: There are no bruits present.,Extremities: Extremities are warm and dry. Distal pulses are full. There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS: He is alert and oriented to person, place and time with good recent and long-term memory. His language is fluent. His attention and concentration are good.,CRANIAL NERVES: Cranial nerves II through XII are intact. VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR: He has normal bulk and tone throughout. There is no cogwheeling. There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5. Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY: He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION: There is no dysmetria or tremor noted. His Romberg is negative. Note that he cannot rise from the chair without using his arms.,GAIT: Upon arising, he has a normal step, stride, and toe, heel. He has difficulty with tandem and tends to fall to the left.,REFLEXES: 2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1. TIA. The character of his brief episode of visual loss is concerning for compromise of the posterior circulation. Differential diagnoses include hypoperfusion, stenosis, and dissection. He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system. He has recently been started on Paxil by his primary care physician and this should be continued. Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup. The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2. Lumbar stenosis. His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability. In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time. Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1. We will get a CT angiogram of the cerebral vessels.,2. Continue Plavix.,3. Obtain copies of the workup done at the outside hospital.,4. We will follow the lumbar stenosis for the time being. No further workup is planned.nan
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HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES: ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES: ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days.discharge summary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,
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REASON FOR REFERRAL:, The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning. The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION: ,Historical information was obtained from a review of available medical records and clinical interview with the patient. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, The patient reported that she had worked as a nurse supervisor for Hospital Center for four years. She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work. She continues to receive some compensation through FMLA hours. She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services. She said that these 90 days are up around the end of November. She said the reason for her dismissal was performance complaints. She said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off. She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays. She described it as a very chaotic and hectic work environment in which she was often putting in extra time. She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time. Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D. He completed a Comprehensive Independent Medical Evaluation on 08/14/2009. She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore. Please note that we do not have copies of any of her work-related correspondence. The patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory." A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation. To summarize, the results indicated "diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history. This suggests that her intellectual functioning has declined." It concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy… The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing. The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other. Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits. His neurological examination on 09/23/2009 was unremarkable. The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting. A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions. Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING: ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her. When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills. She also denied any problems with attention and concentration or forgetfulness or memory problems. She continues to independently perform all activities of daily living. She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning. She reported that if her children had noticed anything they definitely would have brought it to her attention. She said that she does not currently have a lawyer and does not intend to return to her previous physician. She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application. Other current symptoms include excessive fatigue. She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia. She also reported having fallen approximately five times within the past year. She said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging." Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis. She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body. Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal. She denied any significant medical conditions during childhood. As mentioned, she now has a history of fibromyalgia. She also experiences some restriction in the range of motion with her right arm. MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7. MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon. As mentioned, she was diagnosed with chronic fatigue syndrome in 1991. She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control. She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974. Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007. She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night. She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:, NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs. She drinks two to four cups of coffee per day.,SOCIAL HISTORY: ,The patient was born and raised in North Carolina. She was the sixth of nine siblings. Her father was a chef. He completed third grade and died at 60 due to complications of diabetes. Her mother is 93 years old. Her last job was as a janitor. She completed fourth grade. She reported that she has no cognitive problems at this time. Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression. The patient completed a Bachelor of Science in Nursing through State University in 1979. She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems. She was married for two years. Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse. She has two children ages 43 and 30. Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York. In school, the patient reported obtaining primarily A's and B's. She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling. The patient worked for Hospital Center for four years. Prior to that, she worked for an outpatient mental health center for 2-1/2 years. She was reportedly either terminated or laid off and was unsure of the reason for that. Prior to that, she worked for Walter P. Carter Center reportedly for 21 years. She has also worked as an OB nurse in the past. She reported that other than the two instances reported above, she had never been terminated or fired from a job. In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situation. She reported a chronic history of mild sadness or depression, which was relatively stable. When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Testnan
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PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic. The right coronary artery was difficult to cannulate because of its high anterior takeoff. This was nondominant. Several catheters were used. Ultimately, an AL1 diagnostic catheter was used. A pigtail catheter was advanced across the aortic valve. Left ventriculogram was then done in the RAO view using 30 mL of contrast. Pullback gradient was obtained across the aortic valve. Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results. There were no complications. He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1. Right coronary artery: This has an unusual high anterior takeoff. The vessel is nondominant, has diffuse mild-to-moderate disease.,2. Left main trunk: A 30% to 40% distal narrowing is present.,3. Left anterior descending: Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing. The diagonal is a large vessel about 3 mm in size.,4. Circumflex: Dominant vessel, 50% narrowing at the origin of the obtuse marginal. After this, there is 40% narrowing in the AV trunk. The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5. Left ventriculogram: Normal volume in diastole and systole. Normal systolic function is present. There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Dominant circumflex system. Severe disease of the posterior descending. Mild left main trunk disease.,2. Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery. The patient also has severe disease of the circumflex which is dominant. This anatomy is not appropriate for percutaneous intervention. The case will be reviewed with a cardiac surgeon.cardiovascular / pulmonary, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,
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{
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TITLE OF OPERATION:, Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA: ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:, Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in a normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe. The incision was deepened through the subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized. The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved. The bony prominences were removed and passed off the operating table to be sent to pathology for identification. The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp. The area was copiously flushed with saline. Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively. The incision was reinforced with Steri-Strips. Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited. The patient's left ankle tourniquet at this time was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe. The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medications and instructions on how to control her postoperative course. She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.surgery, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal,
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{
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S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1. Onychocryptosis.,surgery, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,
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{
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ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS: ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell. She states that she woke yesterday morning and at approximately 10:30 had a bowel movement. She noticed it was very dark and smelly. She said she felt okay. She got up. She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out. She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools. She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued. She came to place her call, etc. She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday. She denies any nausea except for when she got weak. She denies any vomiting or any other symptoms.,ALLERGIES: ,She has no known drug allergies.,CURRENT MEDICATIONS:,1. Lipitor, dose unknown.,2. Paxil, dose unknown.,3. Lasix, dose unknown.,4. Toprol, dose unknown.,5. Diphenhydramine p.r.n.,6. Ibuprofen p.r.n.,7. Daypro p.r.n.,PAST MEDICAL HISTORY:,1. Non-insulin diabetes mellitus.,2. History of congestive heart failure.,3. History of hypertension.,4. Depression.,5. Arthritis. She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6. Hyperlipidemia.,7. Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:, She is a nonsmoker. She occasionally has a drink every few weeks. She is divorced. She has 2 sons. She is houseparent at Southern University.,REVIEW OF SYSTEMS: ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE: ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS: Currently was stable. She is afebrile.,GENERAL: She is alert, pleasant in no acute distress. She does complain of some dizziness when she stands up.,HEENT: Pupils equal, round and reactive to light. Extraocular muscles intact. Sclerae clear. Oropharynx is clear.,NECK: Supple. Full range of motion.,CARDIOVASCULAR: She is slightly tachycardic but otherwise normal.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended. She has no hepatomegaly.,EXTREMITIES: No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:, Her initial chem panel was within normal limits. Her PT and PTT were normal. Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6. She is currently administered transfusion. Platelet count was 125. Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7. PT and PTT were normal. Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1. Gastrointestinal bleed.nan
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Subsequently, the patient developed a moderately severe depression. She was tried on various medications, which caused sweating, nightmares and perhaps other side effects. She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,Her daughter brought her in today to be sure that she does not have dementia. There is no history of memory loss. There is no history of focal neurologic symptoms or significant headaches.,The patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower. She has no focal neurologic deficits. She does complain of constipation. She has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,The patient was apparently visiting her daughter in northern California in December 2003. She was taken to her daughter's primary care physician. She underwent vitamin B12 level, RPR, T4 and TSH, all of which were normal.,On 05/15/04, the patient underwent MRI scan of the brain. I reviewed the scan in the office today. This shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,PAST MEDICAL HISTORY: , The patient has generally been in reasonably good physical health. She did have a "nervous breakdown" in 1975 after the death of her husband. She was hospitalized for several weeks and was treated with ECT. This occurred while she was living in Korea.,She does not smoke or drink alcoholic beverages. She has had no prior surgeries. There is a past history of hypertension, but this is no longer present.,FAMILY HISTORY: , Negative for dementia. Her mother died of a stroke at the age of 62.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 128/80, pulse 84, temperature 97.4 F, and weight 105 lbs (dressed).,General: Well-developed, well-nourished Korean female in no acute distress.,Head: Normocephalic, without evidence of trauma or bruits.,Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy.,Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status: The patient is awake, alert and oriented to time, place, and person and generally appropriate. She exhibits mild psychomotor retardation and has a flat or depressed affect. She knows the current president of Korea and the current president of the United States. She can recall 3 out of 3 objects after 5 minutes. Calculations are performed fairly well with occasional errors. There is no right-left confusion, finger agnosia, dysnomia or aphasia.,Cranial Nerves:,II:nan
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TITLE OF OPERATION:, Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:, A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus. Consideration given to completion thyroidectomy. Risks, benefits, and alternatives of this procedure was discussed with the patient in great detail. Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management. The patient understood all of this and then wished to proceed.,PREOP DIAGNOSIS:, Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,POSTOP DIAGNOSIS: , Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,PROCEDURE DETAIL:, After identifying the patient, the patient was placed supine in the operating room table. After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm. Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured. The previous skin incision for a thyroidectomy was then planned, then incorporated into an ellipse. The patient was prepped and draped in a sterile fashion. Subsequently, the ellipse around the previous incision was deformed. The scar was then excised. Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively. Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side. There was some dense fibrosis and inflammation surrounding the right thyroid lobe. Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel. The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly, then preserved. Of note is that there were multiple lymph nodes in the paratracheal region on the right side. These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes. The wound was copiously irrigated. Valsalva maneuver was given. Surgicel was placed in the wound bed. Strap muscles were reapproximated in the midline with 3-0 Vicryl and incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin. The patient was extubated in the operating room table, sent to the postanesthesia care unit in good condition.surgery, multifocal thyroid carcinoma, thyroid lobectomy, thyroid, papillary, thyroid lobe, isthmus, completion thyroidectomy, thyroidectomy, paratracheal, lobectomy,
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"dataset_name": "medical-transcription-40",
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REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures. This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother. I have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,PRESENTING PROBLEM: , It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity. These were confirmed by video EEG and consist of trembling, shaking, and things of that nature. She does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality. I had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart. It was reported to me that she has been under considerable stress. First of all, it should be noted that the patient is developmentally delayed. Although she is 17 years old, she operates at about a fourth grade level. Mother reported that The patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset. It is reported, the patient feels that her mother yells at her, and that is mad at her often. It was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison. She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school. She reports that she has no friends that she feels unwanted and picked on. She gets confused easily at school, worries about things, and believes that the teachers become angry with her. In regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her. She sits in the couch, she become angry, does not speak. Mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes. It is reported that the patient has "always been this way" and that is not a change in her behavior. Mother did think that she did seem a little more depressed, that she seems more lonely. Over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored. Mother reported that she frequently complains of being bored, but has always been this way. No sleep disturbance was noted. No changes in weight. No suicidal ideation. No deficits in energy were noted. Mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,DEVELOPMENTAL HISTORY:, The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery. She was delivered at 36 weeks' gestation. Mother reported that she received prenatal care. Difficulties during the pregnancy were denied. The use of drugs, alcohol, tobacco during the pregnancy were denied. No eating or sleeping difficulties during the perinatal period were reported. Temperament was described as easy. The patient is described as a cuddly baby. In terms of serious injuries, they were denied. Serious illnesses: She has been diagnosed since age 5 with seizures. Mother was not able to tell me the exact kind of seizures, but it would appear from I could gather that they are focal seizures and possibly simple-to-complex partial seizures. The patient does not have a history of allergy or toileting problems. She is currently taking Trileptal 450 mg b.i.d., and she is currently taking Depakote, although she is going to be weaned off the Depakote by her neurologist. She is taking Prevacid and ibuprofen. The neurologist that she sees is Dr. Y here at Children's Hospital.,FAMILY BACKGROUND:, In terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays. Mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the ABC area and visits them every other Saturday, but there are no overnight visits. The paternal grandparents are both living here in California, but are separated. They are 3 paternal uncles and 2 paternal aunts. In terms of the maternal family, maternal grandmother and grandfather are deceased. Maternal grandfather deceased in 1991 due to cancer. Maternal grandmother deceased in 2001 due to cancer. There are 5 maternal aunts and 2 maternal uncles, all who live in California. She reported that the patient is particularly close to her maternal aunt, whose name is Carmen. Mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life. In terms of other family background, it was reported that the mother's partner gets frustrated with The patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things. The sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does. The biological father allegedly was in jail for a year due to drug possession. Mother reported that he had a problem with methamphetamine. In addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that. She stated there was no evidence that he had ever molested the patient or her sister. There had been quite a bit of chaos in the family when the mother and father were together. There was a lot of arguing. There were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report. The patient did observe this. After the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them. Mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail. Mother stated that was approximately 5 years ago. In terms of current, mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday, Wednesday's, and Friday's, but she does have the weekends off. The patient was reported also to have a job through her school on several weeknights.,Mother reported that she graduated from high school, had a year of college. She was an average student, had learning difficulties in reading. No psychological or drug or alcohol history was reported by mother. In terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported. Mother reported that he had a history of methamphetamine use.,Other psychiatric history in the family was denied.,SOCIAL HISTORY: , She reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun. Her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that. It was reported that she really feels that she is bored and does not have much to do.,ACADEMIC BACKGROUND: ,The patient is in the 11th grade at High School. She has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education. Mother could not tell me what her IQ was, although she noticed she works at about a 4th or 5th grade level. Mother reported that the terminology most often used with the patient was developmental delay. Her counselor's name is Mr. XYZ, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand. It is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school. She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p.m. where she stocks shelves. It is reported that she does not like to go to school because she feels like nobody likes her. She is not involved in any kind of clubs or groups at school. Mother reported that she is also not receiving CVRC services.,PREVIOUS COUNSELING: , Mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about. She does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,DIAGNOSTIC SUMMARY AND IMPRESSION:, It appears that the patient best qualifies for a diagnosis of conversion disorder, and information from Neurology suggests that the "seizure episodes" are not true seizures, but appear to be pseudoseizures. The patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,PLAN:, My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,DSM IV DIAGNOSES: ,AXIS I: Conversion disorder (300.11).,AXIS II: Diagnoses deferred.,AXIS III: Seizure disorder.,AXIS IV: Problems with primary support group, peer problems, and educational problems.,AXIS V: Global assessment of functioning equals 60.psychiatry / psychology, conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures,
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TITLE OF OPERATION:, Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07. Subsequently, biopsy confirmed tumor persistence in the right glottic region. Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail. Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level. The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives. He was accompanied by his wife and daughter. Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table. After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm. A #6 endotracheal tube was placed initially. Direct laryngoscopy was performed with a Lindholm laryngoscope. A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis. Subsequently, a decision was then made to go ahead and perform the surgical intervention. A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected. A shoulder roll was applied after the patient was prepped and draped in a sterile fashion. Subsequently, a hemi-apron incision was performed. Subplatysmal flaps were raised at the hyoid bone into the clavicle. Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed. Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle. Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle. The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified. Level 2A contents were then dissected off the floor of the neck including levels 3 and 4. Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4. The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve. Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed. Subsequently, the strap muscles were separated in the midline. The trachea was identified in the midline. The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage. Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively. The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular. Attention was then turned to performing a cricothyrotomy. Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision. A #7 anode tube was then placed in this area and secured. Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis. Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine. It was evident that this tumor had extended more than 1 cm into the subglottic region. Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded. Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy. Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin. A W-plasty was also performed to allow for enlargement of the stoma. Attention was then turned to identifying the common parting wall of the trachea and the esophagus. Attention was then turned to resecting the hyoid bone. The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism. The wound was copiously irrigated. Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect. Once this was performed, a running 3-0 canal stitch was used to close the pharynx. Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied. Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon. The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin. The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.surgery, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage
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{
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"dataset_name": "medical-transcription-40",
"id": 1467
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HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.physical medicine - rehab, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles,
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{
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"dataset_name": "medical-transcription-40",
"id": 1468
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PROCEDURE PERFORMED: ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:, After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer: Medtronics.,Model: Sigma.,Model #: 1234.,Serial #: 123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,VENTRICULAR LEAD:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:, Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:, Successful implantation of DDDR permanent pacemaker.,PLAN:,1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. The patient will be placed on antibiotics for five days to avoid pacemaker infection.nan
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{
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ASSESSMENT: ,The patient needed reintubation due to a leaking tube. I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure. His potassium this morning was normal. Using an 8.5 ET tube under direct visualization, the tube was passed through the cords. The patient tolerated the procedure extremely well. Auscultation of the lungs revealed bilateral equal breath sounds. Chest x-ray is pending. CO2 monitor was positive.surgery, et tube, reintubated, postoperative, leakingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
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"dataset_name": "medical-transcription-40",
"id": 1470
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PREOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,OPERATIONS,1. Right common carotid endarterectomy.,2. Right internal carotid endarterectomy.,3. Right external carotid endarterectomy.,4. Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:, General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next the right neck was prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle. Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors. The common, internal and external carotid arteries were identified. The facial vein was ligated with #3-0 silk. The hypoglossal nerve was identified and preserved as it coursed across the carotid artery. After dissecting out an adequate length of common, internal and external carotid artery, heparin was given. Next, an umbilical tape was passed around the common carotid artery. A #0 silk suture was passed around the internal and external carotid arteries. The hypoglossal nerve was identified and preserved. An appropriate sized Argyle shunt was chosen. A Hemashield patch was cut to the appropriate size. Next, vascular clamps were placed on the external carotid artery. DeBakey pickups were used to control the internal carotid artery and common carotid artery. A #11-blade scalpel was used to make an incision on the common carotid artery. The arteriotomy was lengthened onto the internal carotid artery. Next, the Argyle shunt was placed. It was secured in place. Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries. An inversion technique was used on the external carotid artery. The artery was irrigated and free debris was removed. Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion. Prior to completion of our anastomosis, we removed our shunt. We completed the anastomosis. Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery. There was no evidence of bleeding. Full-dose protamine was given. The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion. A sterile dressing was applied.surgery, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1471
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PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. Vital signs were monitored by blood pressure, heart rate, and oxygen saturation. Supplemental O2 given. Specifics of the procedure discussed. The procedure was discussed with father and mother as the patient is mentally challenged. He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year. He went to the emergency department yesterday with beef jerky.,All of this reviewed. The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP. He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency. He has not yet undergone significant workup. He has not yet had an endoscopy or barium study performed. He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture. The patient does not smoke, does not drink. He is living with his parents. Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress. Vital signs monitored in the endoscopy suite. Lungs clear. Cardiac exam showed regular rhythm. Abdomen obese but soft. Extremity exam showed large hands. He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother. Risks, benefits, and alternatives discussed. Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed. The potential need for a barium swallow, modified barium swallow, and similar discussed. All questions answered. At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture. He may have reflux symptoms, without complaining of heartburn. He may benefit from a trial of PPI. All of this reviewed. All questions answered.,surgery, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1472
}
|
CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE: ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1473
}
|
SUBJECTIVE:, The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit. Mom wants to make sure that this is normal. The patient is nursing well every two to three hours. She does have some spitting up on occasion. It has happened two or three times with some curdled appearance x 1. No projectile in nature, nonbilious. Normal voiding and stooling pattern. Growth and Development: Denver II normal, passing all developmental milestones per age. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Mom reports uncomplicated pregnancy with prenatal care provided by Dr. XYZ in Wichita, Kansas. Delivery after induction secondary to postdate at St. Joseph Hospital. Infant delivered by SVD with birth weight of 6 pounds 13 ounce. Length of 19 inches. Did well after delivery and dismissed to home with Mom. Received hepatitis B #1 prior to dismissal. No other hospitalizations. No surgeries. No known medical allergies. No medications. Mom has tried Mylicon drops on occasion.,FAMILY HISTORY: , Significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents. Healthy Mother, Father. There is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today. There is history of asthma in the patient's father.,SOCIAL HISTORY:, The patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, John, who is a supervisor at Excel. The family lives in Bentley, Kansas. No smoking in the home. Family does have one pet cat.,REVIEW OF SYSTEMS:, As per HPI, otherwise, negative.,OBJECTIVE:, Weight: 7 pounds 12 ounces. Height: 21 inches. Head circumference: 35 cm. Temperature: 97.2 degrees.,General: Well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,HEENT: Atraumatic, normocephalic. Anterior fontanel is soft and flat. Pupils are equal, round and reactive. Sclerae clear. Red reflexes present bilaterally. TMs are clear bilaterally. Oropharynx: Mucous membranes are moist and pink.,Neck: Supple, no lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender, nondistended. Positive bowel sounds. No mass nor organomegaly.,Genitourinary: Tanner I female genitalia. Femoral pulses are equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani or Barlow maneuver.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurologic: Alert. Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old white female.,2. Anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule. Gave 2-week well-child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family.,3. Call the office or on-call physician if the patient has fever, feeding problems or breathing problems. Otherwise plan to recheck at 1-month of age.consult - history and phy., well-child check, denver ii, child check, growth, development, denver, cardiovascular, maternal, mother, spitting, father, child, check, asthma, family, mom,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1474
}
|
PREOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1. Incision and drainage of right buccal space abscess.,2. Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1. Aerobic culture was sent from the right buccal space abscess/cellulitis.,2. Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13. The patient was intubated by anesthesia orotracheally using a #7 ET tube. The patient was induced in effective sleep using a propofol and gas inhalation anesthetics. Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack. At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area. Local infiltration also was done near the tooth #32. At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps. In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally. A hemostat was used to puncture through to the right buccal space. Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above. Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space. At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended. Note that the patient was extubated without incident. Dr. B was present for all critical aspects of patient care.dentistry, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1475
}
|
PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3. No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1. Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2. Total laminectomy C3, C4, C5, and C6.,3. Excision of scar tissue.,4. Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:, 1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:, Less than 250 cc.,INDICATIONS FOR THE OPERATION: ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression. Last surgery consisted of four-level decompression on 08/28/06. The patient continued to complain of posterior neck pain radiating to both trapezius. Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis. It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial. Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation. Operation and expected outcome risks and benefits were discussed with him prior to the surgery. Risks include but not exclusive of bleeding and infection. Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection. There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord. This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma. There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis. This too may require return to the operating room for evacuation of said pseudomeningocele and repair. The patient understood the risk of the surgery. I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring. The SSEPs were normal, and the EMGs were silent during the entire case. After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support. Shave was then carried out over the occipital and suboccipital region. All pressure points were padded. I proceeded to mark the hypertrophic scar for excision. This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar. Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified. There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina. With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery. There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel. By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7. There was significant epidural bleeding, which was carefully coagulated. At two points, I had to pack this with small pieces of Gelfoam. After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage. Area was irrigated with saline and bacitracin and then lined with Tisseel. The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch. The patient was extubated and transferred to recovery.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1476
}
|
SUBJECTIVE:, Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:, Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit. There is tenderness to palpation to the medial tubercle of the right foot. The pain is elicited along the medial arch as well. There are no open areas or signs of infection noted.,ASSESSMENT:, Plantar fascitis/heel spur syndrome, right foot.,PLAN:, The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. He was given a low dye strapping and a heel lift was placed in his right shoe. The patient will be seen back in approximately one month for further evaluation if necessary. He was told to call if anything should occur before that. The patient was told to continue with the good work on his diabetic control.soap / chart / progress notes, progress note, plantar fascitis, podiatry, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1477
}
|
EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.radiology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1478
}
|
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops were instilled in the eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus. This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber. The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc. A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps. The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco. This was aided by cracking the lens nucleus with McPherson forceps. The remaining cortex was removed from the eye with the I&A. The capsular bag was then polished with the I&A on capsular bag. The bag was inflated using viscoelastic and then the wound extended slightly with a keratome. A folding posterior chamber lens was inserted and rotated into position using McPherson forceps. The I&A was then placed in the eye again and the remaining viscoelastic removed. The wound was checked for watertightness and found to be watertight. TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.surgery, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1479
}
|
IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , "I am not sure." The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas. According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks. The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle. The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail. The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid. The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY: ,No acute medical problems noted.,CURRENT MEDICATIONS: , None. The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston. The patient has no known history of substances abuse. The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:, Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude: Calm and cooperative.,Appearance: Shows poor hygiene and grooming.,Psychomotor: Behavior is within normal limits without agitation or retardation. No EPS or TDS noted.,Affect: Is suspicious.,Mood: Anxious but cooperative.,Speech: Shows normal rate and rhythm.,Thoughts: Disorganized,Thought Content: Remarkable for paranoia "they want to hurt me.",Psychosis: The patient endorses paranoid delusions as above. The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation: The patient denies on admission.,Cognitive Assessment: Grossly intact. The patient is alert and oriented x 3.,Judgment: Poor, shown by noncompliance with treatment.,Assets: Include stable physical status.,Limitations: Include recurrent psychosis.,FORMULATION: ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I: Schizophrenia, chronic paranoid.,AXIS II: None.,AXIS III: None.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: ,The patient will be restarted on Invega and Abilify for psychosis. The patient will also be continued on Cogentin for EPS. Increased database will be obtained.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1480
}
|
DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized. The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP: ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy: Seroquel 25 mg p.o. nightly. Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:, Attitude was cooperative. Appearance showed fair hygiene and grooming. Psychomotor behavior showed restlessness. No EPS or TD was noted. Affect was restricted. Mood remained anxious and speech was pressured. Thoughts remained tangential, and the patient endorsed paranoid delusions. The patient denied auditory hallucinations. The patient denied suicidal or homicidal ideation, was oriented to person and place. Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment. The patient on admission interview was noted to be labile and disorganized. The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD. The patient remained labile and suspicious during her hospital stay. The patient continued to be sexually preoccupied and had poor insight into her need for treatment. The patient denied further auditory hallucinations. The patient was treated with Seroquel for persistent mood lability and psychosis. The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge. The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies. The patient was thus discharged in symptomatic condition.discharge summary, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1481
}
|
PREOPERATIVE DIAGNOSIS:, Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:, Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:, The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted. Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses. The profundus and the cardia of the stomach were unremarkable. The pylorus was concentric. The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. She was given IV sedation using Demerol and Versed. Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus. Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep. The above gross findings noted. The panendoscope was withdrawn back from the stomach, deflected upon itself. The lesser curve fundus and cardiac were well visualized. Upon examination of these areas, panendoscope was returned to midline. Photographs and biopsies were obtained of the antrum of the stomach. Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate. The patient is sent to recovery room in stable condition.surgery, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1482
}
|
PROCEDURE:, Diagnostic fiberoptic bronchoscopy.,ANESTHESIA: , Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:, ,1. Lortab (10 mg) plus Phenergan (25 mg), p.o. 1 hour before the procedure.,2. Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,surgery, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1483
}
|
CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:, This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:, The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS. There was a normal blood pressure response. The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite. At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1. The overall quality of the study is fair.,2. The left ventricular cavity appears to be normal on the rest and stress studies.,3. SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4. The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal. Result of this test suggests low probability for significant coronary artery disease.radiology, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1484
}
|
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 (inferomedial). The biopsy returned showing infiltrating ductal carcinoma high histologic grade. The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging. She prior to that area, denied any complaints. She had no nipple discharge. No trauma history. She has had been on no estrogen supplementation. She has had no other personal history of breast cancer. Her family history is positive for her mother having breast cancer at age 48. The patient has had no children and no pregnancies. She denies any change in the right breast. Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y. I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy. The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning. The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact. CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:, Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:, She is currently on omeprazole for reflux and indigestion.,ALLERGIES:, SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:, Negative for any recent febrile illnesses, chest pains or shortness of breath. Positive for restless leg syndrome. Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:, Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY: ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL: The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT: Head is atraumatic and normocephalic. Sclerae are anicteric.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,BREASTS: Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle. There are no nipple retractions. No skin dimpling. There is some, at the time of the office visit, ecchymosis from recent biopsy. There is no axillary adenopathy. The remainder of the left breast is without abnormality. The right breast is without abnormality. The axillary areas are negative for adenopathy bilaterally.,ABDOMEN: Soft, nontender without masses. No gross organomegaly. No CVA or flank tenderness.,EXTREMITIES: Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy. We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection. The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient. The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained. Local numbness, paresthesias or chronic pain was explained. The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers. She was certainly encouraged to obtain further surgical medical opinions prior to proceeding. I believe the patient has given full informed consent and desires to proceed with the above.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1485
}
|
PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. He was placed into a well-molded splint after reduction was performed in the emergency department. Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure. The right upper extremity was prepped and draped in a sterile fashion. A 5-cm incision was made over the flexor carpi radialis of the right wrist. The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. Next, a reduction was performed placing the distal fragment into appropriate alignment. This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. An Acumed Accu-lock plate was placed along the volar aspect of the distal radius. This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment. A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. Two distal locking screws were placed along the plate itself. The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. AP and lateral views were taken of these screw placements again. None of these screws were into the joint and all had appropriate length into the dorsal cortex. Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. Bicortical purchase was appreciated and no screws were placed into the joint. The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.orthopedic, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1486
}
|
PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE: ,The patient was electively taken to the operating room. In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery. Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion. Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened. The cord was isolated and protected. It was dissected out. The lipoma of the cord was removed and the sac was high ligated. The main hernia was a direct hernia due to weakness of the floor. A Bassini repair was performed. We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl. The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.surgery, inguinal herniorrhaphy, modified bassini, herniorrhaphy modified bassini, hernia direct, inguinal hernia, inguinal, bassini,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1487
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1. Type I diabetes mellitus.,2. Hyperlipidemia.,3. Hypertension.,4. Morbid obesity.,5. Sleep apnea syndrome.,6. Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General: Unremarkable.,Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal: Unremarkable.,Genitourinary: See above.,Musculoskeletal: Unremarkable.,Neurologic: Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease. His mother has congestive heart failure.,SOCIAL HISTORY: ,The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1. Clonidine 0.3 mg b.i.d.,2. Atenolol 50 mg daily.,3. Simvastatin 80 mg daily.,4. Furosemide 40 mg daily.,5. Metformin 1000 mg b.i.d.,6. Hydralazine 25 mg t.i.d.,7. Diovan 320 mg daily.,8. Lisinopril 40 mg daily.,9. Amlodipine 10 mg daily.,10. Lantus insulin 50 units q.p.m.,11. KCl 20 mEq daily.,12. NovoLog sliding scale insulin coverage.,13. Warfarin 7.5 mg daily.,14. Levothyroxine 0.2 mg daily.,15. Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General: A well-appearing, obese black male.,Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.,HEENT: Grossly normal.,Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.,Chest: Midline sternotomy scar.,Lungs: Clear.,Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.,Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1488
}
|
PREOPERATIVE DIAGNOSES:, OM, chronic, serous, simple or unspecified. Adenoid hyperplasia. Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:, General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:, The procedure, benefits, and risks were discussed in detail preoperatively. The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position. After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope. Serous fluid was aspirated from the middle ear space. An Armstrong grommet tube was placed down through the incision and rotated into place. The opposite ear was then cleaned out under the microscope. Serous fluid was aspirated from the middle ear space. An Armstrong grommet tube was placed down through the incision and rotated into place. Cortisporin suspension was placed in both ear canals.,Then the patient was intubated. A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand. The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate. The adenoid fossa was visualized with the mirror. The adenoids were removed using the microdebrider. Two adenoid packs were placed. The packs were removed one by one. Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic. The tenaculum was placed on the superior pole of the right tonsil. Cheesy material came out from the crypts. The tonsils were retracted medially. The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature. The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars. All bleeders were cauterized as they were encountered. The tenaculum was then placed on the superior pole of the left tonsil. Cheesy material came out from the crypts. The tonsils were retracted medially. The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature. The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars. All bleeders were cauterized as they were encountered. Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube. The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.surgery, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1489
}
|
HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.consult - history and phy., colon cancer screening, loose stools, colorectal, colonoscopy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1490
}
|
PREOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.,ANESTHESIA:, General LMA.,SPECIMEN: , Old triple component inflatable penile prosthesis.,PROCEDURE: ,This is a 64-year-old male with prior history of Peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,OPERATIVE PROCEDURE: , After informed consent, the patient was brought to the operative suite and placed in the supine position. General endotracheal intubation was performed by the Anesthesia Department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra. The bladder was subsequently drained with a red Robinson catheter. At that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space. Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture. At that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies. Attention was taken then to the tubing, going up to the reservoir in the right lower quadrant. This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis. At this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis. As we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery. At that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum. This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 Prolene stay ties, staying lateral and anterior on the corporal body. The corporal body was opened up and the cylinder was removed from the right side without difficulty. However, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures. This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body. The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted. After removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen. Both corporal bodies were then dilated with the Pratt dilators. These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces. At this point, using the Farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally. He had an 18 cm with rear tips in place, which were removed. We decided to go ahead to and use another 18 cm inflatable penile prosthesis. Confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest. We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm. At this point, we went ahead and placed the right cylinder using the Farlow device and the Keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty. Attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders. This then forced us to down size to the 1 cm rear tips, which slipping very easily with the Farlow device through the glans penis. There was no crossover and no violation of the tunica albuginea. The rear tips were then placed without difficulty and our corporotomies were closed with #2-0 PDS in a running fashion. ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants. At that point, the wound was copiously irrigated and the device was inflated multiple times. There was a very good fit and we had a very good result. At that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution. This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump. Please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 Vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty. The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated. After completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result. At that point, after irrigation again of the space, the area was simply dry and hemostatic. The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers. The soft tissue and the skin was then reapproximated with staples. Please also note that prior to the skin closure, a Jackson-Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours. This was also sutured in place with nylon. Sterile dressing was applied. Light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally. Coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine. No Foley catheter was used or placed.,The patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition. He will be admitted overnight to the service of Dr. McDevitt. Cardiology will be asked to consult with Dr. Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics.urology, inflatable penile prosthesis, peyronie's disease, perineum, scrotum, penis, penile prosthesis, bovie cautery, corporal body, glans penis, pump, cylinders, penile, prosthesis, inflatable, corporal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1491
}
|
CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:, BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.neurology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1492
}
|
PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3. Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement. Motor stimulation was applied at 2 Hz with 1 millisecond duration. No extremity movement was noted at less than 2 volts. Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue. After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.pain management, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1493
}
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PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Sigmoid and left colon diverticulosis.,2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. If there is further bleeding, a full colonoscopy is recommended.surgery, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1494
}
|
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 identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties.,ALLERGIES:, Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1. Heparin.,2. Albuterol inhaler.,3. Combivent.,4. Aldactone.,5. Doxepin.,6. Xanax.,7. Aspirin.,8. Amiodarone.,9. Tegretol.,10. Synthroid.,11. Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:, Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT: Oropharynx clear.,CV: Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended. Bowel sounds positive.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out.,IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty.,2. History of panic attack, anxiety, depression.,3. Myocardial infarction with stent placement.,4. Hypertension.,5. Hypothyroidism.,6. Subdural hematoma.,7. Seizures.,8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency.,9. Renal insufficiency.,10. Recent pneumonia.,11. O2 requiring.,12. Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1495
}
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PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:, The patient was taken to the GI lab and placed in the left lateral supine position. Continuous pulse oximetry and blood pressure monitoring were in place. After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty. With swallowing, the scope was advanced down the esophagus into the body of the stomach. The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion. It appeared free of stricture, neoplasm, or ulceration. Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology. Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia. The scope was then slowly removed. The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis. The remaining portion of the esophagus was normal.,IMPRESSION:, Abdominal pain. Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:, Await results of CLO testing and biopsies. Return to clinic with Dr. Spencer in 2 weeks for further discussion.gastroenterology, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1496
}
|
PREOPERATIVE DIAGNOSIS:, Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for. The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap. He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty. After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty. He had previously undergone a CT scan. Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed. We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant. He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis. The scalp was prepped and draped in the usual sterile fashion. A previous incision was reopened and the scalp flap was reflected forward. We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap. We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base. We did explore laterally and saw a little bit of the mesh on the lateral orbit. Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws. We had achieved good hemostasis. The wound was closed in multiple layers in usual fashion over a Blake drain. At the end of the procedure, all sponge and needle counts were correct. A sterile dressing was applied to the incision. The patient was transported to the recovery room in good condition after having tolerated the procedure well. I was personally present and scrubbed and performed/supervised all key portions.neurosurgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1497
}
|
PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room.surgery, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1498
}
|
PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:, Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.surgery, hemostasis, excision, pilonidal cyst, cyst, abscess, infected,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 1499
}
|
CHIEF COMPLAINT:, Multiple problems, main one is chest pain at night.,HISTORY OF PRESENT ILLNESS:, This is a 60-year-old female with multiple problems as numbered below:,1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month. She wakes in the middle of the night and reports that she has a pressure. It is mild-to-moderate in the middle of her chest and will stay there as long she lies down. If she gets up, it goes away within 15 minutes. It is currently been gone on for the last week. She denies any fast heartbeats or irregular heartbeats at this time.,2. She has been having stomach pains that started about a month ago. This occurs during the daytime. It has no relationship to foods. It is mild in nature, located in the mid epigastric area. It has been better for one week as well.,3. She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms. If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4. She has right flank pain when she lies down. She has had this off and on for four months. It is a dull achy pain. It is mild in nature.,5. She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past. It is not painful.,6. She has had spots in her armpits initially on the right side and then going to the left side. They are not itchy.,7. She is having problems with urgency of urine. When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking. She is wearing a pad now.,8. She is requesting a colonoscopy for screening as well. She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9. She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months. There has been no swelling or redness or trauma to these areas.,REVIEW OF SYSTEMS:, She has recently been to the eye doctor. She has noticed some hearing loss gradually. She denies any problems with swallowing. She denies episodes of shortness of breath, although she has had a little bit of chronic cough. She has had normal bowel movements. Denies any black or bloody stools, diarrhea, or constipation. Denies seeing blood in her urine and has had no urinary problems other than what is stated above. She has had no problems with edema or lower extremity numbness or tingling.,SOCIAL HISTORY:, She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972.,FAMILY HISTORY: , Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker.,PAST MEDICAL HISTORY:, Episodic leukopenia and mild irritable bowel syndrome.,CURRENT MEDICATIONS:, Aciphex 20 mg q.d. and aspirin 81 mg q.d.,ALLERGIES:, No known medical allergies.,OBJECTIVE:,Vital Signs: Weight: 142 pounds. Blood pressure: 132/78. Pulse: 72.,General: This is a well-developed adult female who is awake, alert, and in no acute distress.,HEENT: Her pupils are equally round and reactive to light. Conjunctivae are white. TMs look normal bilaterally. Oropharynx appears to be normal. Dentition is excellent.,Neck: Supple without lymphadenopathy or thyromegaly.,Lungs: Clear with normal respiratory effort.,Heart: Regular rhythm and rate without murmur. Radial pulses are normal bilaterally.,Abdomen: Soft, nontender, and nondistended without organomegaly.,Extremities: Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint. Her armpits are examined. She has what appears to be a tinea versicolor rash present in the armpits bilaterally. She has a lesion on her left shoulder, which is 6 mm in diameter. It has diffuse borders and is slightly red. It has two brown spots in it. In her lower extremities, there is no cyanosis or edema. Pulses at the radial and posterior tibial pulses are normal bilaterally. Her gait is normal.,Psychiatric: Her affect is pleasant and positive.,Neurological: She is grossly intact. Her speech seems to be clear. Her coordination of upper and lower extremities is normal.,ASSESSMENT/PLAN:,1. Chest pain. At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac. My intonation is that this is reflux. I am going have her double her Aciphex or increase it to b.i.d., and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate. She is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2. Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain.,3. Suspicious lesions on the left shoulder. We will do a punch biopsy and set her up for an appointment for that.,4. Tinea versicolor in the axillary area. I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5. Cystocele. We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence.,6. History of leukopenia. We will check a CBC.,7. Pain in the thumbs, probably arthritic in nature, observe for now.,8. Screening. We will have her see Dr. XYZ for discussion of colon cancer screening.,9. Gastroesophageal reflux disease. I have increased Aciphex to b.i.d. for now.nan
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