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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 800
}
|
PREOPERATIVE DIAGNOSIS:, Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid. The patient was given Ancef preop antibiotic. Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam. There was no evidence of cystocele or rectocele. On urodyanamcis, the patient has significant overactivity of the bladder. The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each. The patient had pretty much failure from each of the procedure. The patient had less than 20% improvement with anticholinergics. Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed. The patient was interested in the trial. The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence. The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator. Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient. The patient understood and wanted to proceed with stage I and II neuromodulator. Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR. The patient was placed in prone position. A pillow was placed underneath her pelvis area to slightly lift the pelvis up. The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues. The patient's back was prepped and draped in the usual sterile fashion. Lidocaine 1% was applied on the right side near the S3 foramen. Under fluoroscopy, the needle placement was confirmed. The patient felt stimulation in the vaginal area, which was tapping in nature. The patient also had a pressure feeling in the vaginal area. The patient had no back sensation or superficial sensation. There was no sensation down the leg. The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle. A wire was placed. The tract was dilated and lead was placed. The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position. Most of the leads had very low amplitude and stimulation. Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks. Please note that the lidocaine was injected prior to the tunneling. A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead. Screws were turned and they were dropped. Attention was made to ensure that the lead was all the way in into the InterStim. Irrigation was performed after placing the main unit in the pouch. Impedance was checked. Irrigation was again performed with antibiotic irrigation solution. The needle site was closed using 4-0 Monocryl. The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl. Dermabond was applied.,The patient was brought to recovery in a stable condition.urology, refractory urgency, urgency, frequency, neuromodulator, subcutaneous tissue, interstim,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 801
}
|
PREOPERATIVE DIAGNOSIS:, Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:, Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:, The rectal chamber revealed no external lesions. Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum. The position of the scope within the cecum was verified by identification of the ileocecal valve. Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen. There was not even a scar representing the prior polyp. I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all. The scope was then slowly withdrawn. In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma. It was freely mobile and very small with normal overlying mucosa. There was a similar lesion in the descending colon. Both of these appeared to be lipomatous, so no attempt was made to remove them. There were diverticula present in the sigmoid colon. In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery. There was no bleeding. The scope was then withdrawn. The rectum was normal. When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare. There was no specimen and there was no bleeding. The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1. Small polyps, sigmoid colon, resected them.,2. Diverticulosis, sigmoid colon.,3. Small rectal polyps, obliterated them.,4. Submucosal lesions, consistent with lipomata as described.,5. No evidence of residual or recurrent neoplasm in the cecum.gastroenterology, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 802
}
|
PREOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,3. 8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED: ,Laparoscopic right salpingooophorectomy.,ANESTHESIA: ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:, None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass. Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice. Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits. There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:, The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity. The pain persisted despite multiple pain medications given in the Emergency Room. The patient reports positive nausea and vomiting. There was no vaginal bleeding or discharge. There was no fevers or chills. Her cultures done in the Emergency Room were pending. The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic. The uterus and left ovary were within normal limits. There was a positive flow noted to bilateral ovaries on ultrasound. Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:, After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty. She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion. Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above. She was prepped and draped in the usual sterile fashion. A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix. The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field. The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed. The vulsellum tenaculum was removed. The weighted speculum was removed. Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold. The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp. The CO2 was then turned on with unoccluded flow and excellent pressures. This was continued till a normal symmetrical pneumoperitoneum was obtained. Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope. Laparoscopic findings are as noted above. A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization. Then, a grasper was used to untorse the ovary. Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system. The right tube and ovary were amputated and noted to be hemostatic. The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag. The ovary was too large to fit completely into the bag. Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst. This was a clear yellow fluid. Then, the bag was closed and the ovary was removed from the suprapubic port. The suprapubic port did have to be extended somewhat to allow for the removal of the ovary. The trocar and sleeve were then placed back into the port. The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic. The pelvis was clear and clean. ,Pictures were obtained. The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6. Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed. Therefore, the peritoneal surface was noted to be hemostatic. Therefore, the camera was removed. All instruments were removed. The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed. The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6. The right flank area was palpated and there was no facial defect noted. The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion. Dressings were changed. The weighted speculum was removed from the patient's cervix. The cervix noted to be hemostatic. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 803
}
|
REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:, The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy. Unfortunately, she had miscarriage at about seven weeks. She again had abdominal cramping, severe, in late March 2007. She underwent colonoscopy on 04/30/2007 by Dr. Y. Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure. She was not able to have the scope passed past this lesion. Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday. The surgery was laparoscopic assisted with anastomosis. At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis. There was no angiolymphatic invasion noted. Radial margin was 0.1 mm. Other margins were 5 and 6 mm. Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis. This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs. The degenerative changes were noted at L5-S1. The ovaries were normal. An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:, She has otherwise been feeling well. She has not had fevers, night sweats, or noticed lymphadenopathy. She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber. She was eating well up until the time of her surgery. She is up-to-date on mammography, which will be due again in June. She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:, None.,PAST MEDICAL HISTORY: , No significant medical problem. She has had three miscarriages, all of them at about seven weeks. She has no prior surgeries.,SOCIAL HISTORY: ,She smoked cigarettes socially while in her 20s. A pack of cigarettes would last for more than a week. She does not smoke now. She has two glasses of wine per day, both red and white wine. She is married and has no children. An IUD was recently placed. She works as an esthetician.,FAMILY HISTORY: ,Father died of stage IV colon cancer at age 45. This occurred when the patient was young and she is not sure of the rest of the paternal family history. She does believe that aunts and uncles on that side may have died early. Her brother died of pancreas cancer at age 44. Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago. Otherwise, he has no medical problem. Mother is aged 82 and healthy. She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL: She is in no acute distress.,VITAL SIGNS: The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN: Warm and dry. She has no jaundice.,LYMPHATICS: No cervical or supraclavicular lymph nodes are palpable.,LUNGS: There is no respiratory distress.,CARDIAC: Regular rate.,ABDOMEN: Soft and mildly tender. Dressings are clean and dry.,EXTREMITIES: No peripheral edema is noted. Sequential compression devices (SCDs) are in place.,LABORATORY DATA:, White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6. Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133. Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis. Firstly, she has a good prognosis for being cured without adjuvant therapy. I would consider her borderline for chemotherapy given her young age. Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit. Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects. We did not review all that information today.,She has a family history of early colon cancer. Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can. Tumor is being tested for microsatellite instability and we will discuss this when those results are available. She has one sibling and he is up-to-date on colonoscopy. She does report multiple tubes of blood were drawn prior to her admission. I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed. If not, those can be drawn tomorrow.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 804
}
|
SUBJECTIVE: , This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was something else. He says he is having a lot of palpitations. He gets a fluttering feeling in his chest. He has been very tired over two weeks as well. His job has been really getting to him. He has been feeling nervous and anxious. It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. These symptoms are not triggered by exertion. He had similar symptoms about 9 or 10 years ago. At that time he went through a full workup. Everything ended up being negative and they gave him something that he took for his nerves and he says that helped. Unfortunately, he does not remember what it was. Also over the last three days he has had some intestinal problems. He has had some intermittent nausea and his stools have been loose. He has been having some really funny green color to his bowel movements. There has been no blood in the stool. He is not having any abdominal pain, just some nausea. He does not have much of an appetite. He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16. General exam: The patient is nontoxic and in no acute distress. There is no labored breathing. Psychiatric: He is alert and oriented times 3. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Eyes: Pupils equal, round, and reactive to light bilaterally. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing.,ASSESSMENT: ,1. Palpitations, possibly related to anxiety.,2. Fatigue.,3. Loose stools with some green color and also some nausea. There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks. He says his work is definitely contributing to some of his symptoms and he feels stressed. He is leaving for a vacation very soon. Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him. My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis. A 12-lead EKG was performed on him in the office today. This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news. I am going to send him to the lab from our office to get the following tests done: Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray. Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital. We were able to squeeze him in. His appointment is at 8:15 in the morning. He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck. I am not going to be here so he is going to see Dr. X. Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ. Certainly, if something comes up we may need to postpone his trip. We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago. In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety. I talked about Ativan, how it works. I talked about the side effects. I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck. I took him off of work today and tomorrow so he could rest.soap / chart / progress notes, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 805
}
|
ADMISSION DIAGNOSES: ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED: ,Hemiarthroplasty, right hip.,CONSULTATIONS: ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip. The patient was admitted to Orthopedics and consulted Medicine. The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence. The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's. Brief elevation of white count following the surgery, which did subside. Studies, UA and blood culture were negative. The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:, Transfer to ABC for rehab and continued care. Diabetic diet. Activity, ambulate as tolerated with posterior hip precautions. Rehab potential fair. He will need nursing, Social Work, PT/OT, and nutrition consults. Resume home meds, DVT prophylaxis, aspirin, and compression stockings. Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.orthopedic, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 806
}
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REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure. The patient also has a very extensive cardiac history that would be outlined below. He is being admitted with worsening shortness of breath and constipation. He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1. Benign prostatic hypertrophy.,2. Peptic ulcer disease.,3. Atrial fibrillation.,4. Coronary artery disease.,5. Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6. ICD implantation.,7. Peripheral vascular disease.,8. CABG in 1991 and 1998.,9. Congestive heart failure, EF 40%.,10. Asbestos exposure.,MEDICATIONS,1. Coumadin 6 mg alternating with 9 mg.,2. Prevacid 30 mg once a day.,3. Diovan 160 mg every day.,4. Flomax 0.4 mg every day.,5. Coreg 25 mg in the morning and 12.5 mg at night.,6. Aldactone 25 mg a day.,7. Lasix 20 mg a day.,8. Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL: The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS: Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT: Significant for peripheral cyanosis.,NECK: Supple.,LUNGS: Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR: Regular rate and rhythm with murmur and metallic click.,ABDOMEN: Soft and benign.,EXTREMITIES: 1+ cyanosis. No clubbing. No edema.,LABORATORY DATA:, Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000. CK 266, PTT 37, PT 34, and INR 3.7. Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1. Hemoptysis.,2. Acute bronchitis.,3. Coagulopathy.,4. Asbestos exposure.,5. Left pleural effusion.,RECOMMENDATIONS,1. Antibiotics.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 807
}
|
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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 808
}
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CHIEF COMPLAINT:, Status epilepticus.,HISTORY OF PRESENT ILLNESS: ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. At baseline, he can put about 2 to 4 words together in brief sentences. His speech is not always easily understood; however, he is in a special education classroom in kindergarten. He ambulates independently, but falls often. He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left. Mother reports he postures the left upper extremity when running. He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X. He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago. These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side. His events, however, always tend to be prolonged. He has had seizures as long as an hour and a half. He tends to require multiple medications to stop them. He has been followed by Dr. Y and was started on Trileptal. At one point, The patient was taken off his medication for presumed failure to prevent his seizures. He was more recently placed on Topamax since March 2007. His last seizures were in March and May respectively. He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure. His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right. Family administered Diastat 7.5 mg x1 dose. They did not know they could repeat this dose. EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin. His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline. He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise. He does have some fevers after his prolonged seizures. He denies any respiratory or cardiovascular complaints. There is no numbness or loss of skills. He has no rashes, arthritis or arthralgias. He has no oropharyngeal complaints. Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings. There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS: His vital signs are stable and he is currently afebrile.,HEENT: Atraumatic and normocephalic. Oropharynx shows no lesions.,NECK: Supple without adenopathy.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm, no murmurs.,ABDOMEN: Benign without organomegaly.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: The patient is alert and will follow instructions. His speech is very dysarthric and he tends to run his words together. He is about 50% understandable at best. He does put words and sentences together. His cranial nerves reveal his pupils are equal, round, and reactive to light. His extraocular movements are intact. His visual fields are full. Disks are sharp bilaterally. His face shows left facial weakness postictally. His palate elevates midline. Vision is intact bilaterally. Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline. His left thigh is abducted at the hip at rest with the right thigh and leg straight. He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria. Right upper extremity is much more on target. His sensations are intact to light touch bilaterally. Deep tendon reflexes are 2+ and symmetric. When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis. He also shows some scoliotic curve of the spine, which is mild at this point. Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage. He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day. At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently. The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily. Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence. I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance. The plan from CT standpoint is to continue stretching program, continue with medical therapy unit. He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before. They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time. Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them. Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 809
}
|
PREOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1. Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2. Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3. Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:, None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition. Informed consent was obtained from the patient. All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. Each of the areas was cleaned with a sterile alcohol swab. Planned excision site was marked with a marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions. The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. However, it is somewhat deeper than the standard seborrheic keratosis. The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus. It was excised with a defect 0.5 x 0.5 cm. It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. Sterile dressing was applied afterwards. The patient was discharged in stable condition. Postop care instructions reviewed in detail. She is scheduled with me in one week and we will make further recommendations at that time.surgery, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 810
}
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REASON FOR CONSULTATION:, Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia. The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. Foley catheter was repositioned 18 Coude was used. About over a liter of fluids of urine was obtained with light pink urine, which was irrigated. The bladder and the suprapubic area returned to normal after the Foley placement. The patient had some evidence of clots upon irrigation. The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY: ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:, No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting. Does have suprapubic tenderness and difficulty voiding. The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is afebrile. Vitals are stable.,GENERAL: The patient is a thin gentleman,GENITOURINARY: Suprapubic area was distended and bladder was palpated very easily. Prostate was 1+. Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000. Creatinine is normal.,ASSESSMENT AND PLAN:,1. Pneumonia.,2. Dehydration.,3. Retention.,4. BPH.,5. Diabetes.,6. Hyperlipidemia.,7. Parkinson's.,8. Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained. Plan is for urine culture, antibiotics. Plan is for renal ultrasound to rule out any pathology. The patient will need cystoscopy and evaluation of the prostate. Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time. Continued Foley catheter at this point. We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 811
}
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PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE: ,Adenotonsillectomy.,COMPLICATIONS:, None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed. A similar procedure was performed on the contralateral tonsil. Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted. The patient was then allowed to awaken and was brought to the recovery room in stable condition.ent - otolaryngology, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 812
}
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CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, "Fleet enema." ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 813
}
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PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.ophthalmology, trabeculectomy, kelly-descemet punch, maxitrol ointment, open angle glaucoma, tg needle, bleeding, corneal edema, corneal hemorrhage hypotony, diplopia, elevated pressure, glaucoma, infection, iridectomy, loss of the eye, loss of vision, mitomycin c, ptosis, reoperation, retinal detachment, temporal paracentesis, worsening of glaucoma, balanced salt solution, anterior chamber, scleral flap, eye, angle, mitomycin, conjunctival, chamber, flap,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 814
}
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CHIEF COMPLAINT:, This 26-year-old male presents today for a complete eye examination.,ALLERGIES:, Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:, Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:, Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:, Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils: Pupil exam reveals round and equally reactive to light and accommodation.,Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields: Confrontation VF exam reveals full to finger confrontation O.U.,IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving.,Keratometry:,OD: K1 35.875K2 35.875,OS: K1 35.875K2 41.875,Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.,Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.,Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens: Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping.,Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15.,REFRACTION:,Lenses - final:,OD: +0.50 +1.50 X 125 Prism 1.75,OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add: OD: +1.00 OS: +1.00,OU: Far VA 20/25,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Eye and vision exam normal.,PLAN:, Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 815
}
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FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax. A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back. The sample will then be sent for testing. The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information. A booklet containing the description of the procedure and other information was provided.cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: 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": 816
}
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PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA: ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION: ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon. There was some softening and loss of the articular cartilage over the glenoid. The labrum was ________ attached permanently to the glenoid. The biceps tendon was nonsubluxable. Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side. Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space. There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:, This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder. MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position. After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion. The left extremity was prepped and draped in usual fashion. The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect. We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion. A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder. A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula. The operative findings found intra-articularly were as described previously gross operative findings. We did not see any evidence of acute pathology. We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline. The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal. All this was done and hemostasis was achieved. The rotator cuff was examined from the bursal side and showed no evidence of tears. There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver. We removed all of our instruments and suctioned the subacromial space dry. A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling. She was placed back on the gurney, extubated and taken to the PACU in stable condition.orthopedic, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 817
}
|
REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. The patient had some cardiac workup in the past, results are as mentioned below. Denies any specific chest pain. Activities fairly stable. She is actively employed. No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus. Nonsmoker. Cholesterol normal. No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:, SULFA.,PERSONAL HISTORY: , She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past. Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal. Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal. An echocardiogram at that time was also normal. At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Nonsignificant.,NEUROLOGICAL: No TIA. No CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGIC: Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No carotid bruits. No thyromegaly. No lympyhadenopathy.,LUNGS: Air entry bilaterally fair.,HEART: PMI normal. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Benign.,PSYCHOLOGICAL: Normal.,MUSCULOSKELETAL: Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:, H&H stable. BUN and creatinine within normal limits. Cardiac enzyme profile negative. Chest x-ray unremarkable.,IMPRESSION:,1. Lightheaded, dizziness in a 50-year-old female. No documented arrhythmia with the symptoms of palpitation.,2. Normal cardiac structure by echocardiogram a year and half ago.,3. Normal cardiac catheterization in 11/07.,4. Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 818
}
|
IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height. He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:, Prior to admission, we do not have that information. He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY: ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude: The patient is unresponsive.,Appearance: He is lying in bed in the fetal position with a blanket over his head.,Psychomotor: Catatonic.,EPS/TD: Unable to assess though his limbs are quite contracted.,Affect: Unresponsive.,Mood: Unresponsive.,Speech: Unresponsive.,Thought Process And Thought Content: Unresponsive.,Psychosis: Unable to elicit information to make this assessment.,Suicidal/Homicidal: Also unable to elicit this information.,Cognitive Assessment: Unable to elicit.,Judgment And Insight: Unable to elicit.,Assets: The patient is young.,Limitations: Severe decompensation.,FORMULATION: ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I: Psychosis, NOS.,AXIS II: Deferred.,AXIS III: Dehydration.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1. Stabilize medically from the dehydration per internal medicine.,2. Medications, milieu therapy to assist with re-compensation.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 819
}
|
CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse. He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:, Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS: ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS: ,Documented on the template. Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. Oxygen saturation low at 91% on room air.,GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular motions are intact and conjugate. Clear TMs, nose, and oropharynx.,NECK: Supple. Full painless nontender range of motion.,CHEST: Tight wheezing and retractions heard bilaterally.,HEART: Regular without rubs or murmurs.,ABDOMEN: Soft, nontender. No masses. No hepatosplenomegaly.,GENITALIA: Male genitalia is present on a visual examination.,SKIN: No significant bruising, lesions or rash.,EXTREMITIES: Moves all extremities without difficulty, nontender. No deformity.,NEUROLOGIC: Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:, The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. She is further treated in the emergency department with continued breathing treatments. At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells. Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 820
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 821
}
|
PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:, MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1. Left frontal craniotomy for placement of deep brain stimulator electrode.,2. Right frontal craniotomy for placement of deep brain stimulator electrode.,3. Microelectrode recording of deep brain structures.,4. Stereotactic volumetric CT scan of head for target coordinate determination.,5. Intraoperative programming and assessment of device.,INDICATIONS: ,The patient is a 61-year-old woman with a history of dystonic tremor. The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation. The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives. She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:, The patient was brought to the holding area and to the operating room in stable condition. She was placed on the operating table in seated position. Her head was shaved. Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes. IV antibiotics were administered as was the sedation. She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken. The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen. Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint. Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again. Foley catheter was placed, and she was secured to the table using the Mayfield unit. At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes. Sterile drapes placed around the perimeter of the field. This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings. Bur holes were created on either side of the midline just behind the coronal suture. Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field. Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill. The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade. The cortical surface was then nicked with a #11 blade on both sides as well. The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame. Microelectrode drive was secured to the arc. Microelectrode recording was then performed. The signatures of the cells were recognized. Microelectrode unit was removed. Deep brain stimulating electrode holding unit was mounted. The DBS electrode was then loaded into target and intraoperative programming and testing was performed. Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side. This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system. The microelectrode unit was then remounted. Microelectrode recording was then undertaken. After multiple passes, the microelectrode unit was removed. Deep brain stimulator electrode holding unit was mounted at the desired trajectory. The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box. Using standard parameters, the patient experienced similar results on her right side. This electrode was secured using bur-hole ring and cap system. The arc was then removed. A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally. Copious amounts of Betadine irrigation were used. Hemostasis was controlled using the bipolar only. Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples. Sterile dressings were applied. The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition. All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.neurology, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 822
}
|
REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.,PAST MEDICAL HISTORY:, Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin. She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.,REVIEW OF SYSTEMS: ,The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:hematology - oncology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 823
}
|
OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1. Colon cancer screening.,2. Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Multiple colon polyps (5).,2. Diverticulosis, sigmoid colon.,3. Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES: ,Biopsies taken from all polyps. Hot biopsy got applied to one. Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses. Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE: ,The patient was placed in left lateral decubitus after appropriate sedation. Digital rectal examination was done, which was normal. Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen. It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine. Pedunculated polyp next to it was hard to see and there was a lot of peristalsis. The scope then was advanced through rest of the transverse colon to ascending colon and cecum. Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out. Ascending colon was unremarkable. At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen. In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy. Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy. Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy. The rest of the splenic flexure and descending colon were unremarkable. Diverticulosis was again seen with almost constant spasm despite of glucagon. Sigmoid colon did somewhat hinder the inspection of that area. Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large. Excess of air insufflated was removed. The endoscope was withdrawn.,PLAN: , Await biopsy report. Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.surgery, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 824
}
|
HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition.emergency room reports, acute episode of agitation, agitation,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 825
}
|
SUBJECTIVE:, The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. She has had it for about a year, but seems to be worsening. She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot. They are not worse with walking. It seems to be worse when she is in bed. There is some radiation of the pain up her leg. She also continues to have bilateral shoulder pains without sinus allergies. She has hypothyroidism. She has thrombocythemia, insomnia, and hypertension.,PAST MEDICAL HISTORY:, Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002. She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004. She has had a number of colonoscopies; next one is being scheduled at the end of this month. She also had a right total knee arthroplasty in 1993. She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004.,ALLERGIES: , Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine.,CURRENT MEDICATIONS:, Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n.,SOCIAL HISTORY:, She is a nonsmoker and nondrinker. She has been widowed for 18 years. She lives alone at home. She is retired from running a restaurant.,FAMILY HISTORY:, Mother died at age 79 of a stroke. Father died at age 91 of old age. Her brother had prostate cancer. She has one brother living. No family history of heart disease or diabetes.,REVIEW OF SYSTEMS:,General: Negative.,HEENT: She does complain of some allergies, sneezing, and sore throat. She wears glasses.,Pulmonary history: She has bit of a cough with her allergies.,Cardiovascular history: Negative for chest pain or palpitations. She does have hypertension.,GI history: Negative for abdominal pain or blood in the stool.,GU history: Negative for dysuria or frequency. She empties okay.,Neurologic history: Positive for paresthesias to the toes of both feet, worse on the right.,Musculoskeletal history: Positive for shoulder pain.,Psychiatric history: Positive for insomnia.,Dermatologic history: Positive for a spot on her right cheek, which she was afraid was a precancerous condition.,Metabolic history: She has hypothyroidism.,Hematologic history: Positive for essential thrombocythemia and anemia.,OBJECTIVE:,General: She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs: Her age is 81. Temperature: 98.0. Blood pressure: 140/70. Pulse: 72. Weight: 127.,HEENT: Head was normocephalic. Pupils equal, round, and reactive to light. Extraocular movements are intact. Fundi are benign. TMs, nares, and throat were clear.,Neck: Supple without adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur, click, or rub. No carotid bruits are heard.,Abdomen: Normal bowel sounds. It is soft and nontender without hepatosplenomegaly or mass.,Breasts: Surgically absent. No chest wall mass was noted, except for the Port-A-Cath in the left chest. No axillary adenopathy is noted.,Extremities: Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities. There is a cyst on the anterior portion of the right ankle. Pedal pulses were present.,Neurologic: Cranial nerves II-XII grossly intact and symmetric. Deep tendon reflexes were 1 to 2+ bilaterally at the knees. No focal neurologic deficits were observed.,Pelvic: BUS and external genitalia were atrophic. Vaginal rugae were atrophic. Cervix was surgically absent. Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.,Rectal: Exam confirmed there is brown stool present in the rectal vault.,Skin: Clear other than actinic keratosis on the right cheek.,Psychiatric: Affect is normal.,ASSESSMENT:,1. Peripheral neuropathy primarily of the right foot.,2. Hypertension.,3. Hypothyroidism.,4. Essential thrombocythemia.,5. Allergic rhinitis.,6. Insomnia.,PLAN:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 826
}
|
PROCEDURE:,1. Implantation, dual chamber ICD.,2. Fluoroscopy.,3. Defibrillation threshold testing.,4. Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room. The patient was prepped and draped in a sterile fashion. Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully. Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein. Venogram was then performed. Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava. A second guidewire was placed in a similar fashion. Approximately a 5 cm incision was made in the left upper anterior chest. The skin and subcutaneous tissue was dissected out of the prepectoral fascia. Both guide wires were brought into the pocket area. A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava. The dilator and guidewire were removed. A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle. Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex. After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture. A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava. The dilator and guidewire were removed. An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium. Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area. After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture. The tract was flushed with saline solution. A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture. Deep and superficial layers were closed with 3-0 Vicryl in a running fashion. Steri-strips were placed over the incision. Tegaderm was placed over the Steri-strips. Pressure dressing was applied to the pocket area.cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 827
}
|
CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS: ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days. He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS: ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. HEENT: PERRLA. EOMI. Conjunctivae anicteric. Skull is normocephalic. He is not complaining of bruising. HEENT: TMs and canals are normal. There is no Battle sign. NECK: Supple. He has good range of motion. Spinal processes are normal to palpation. LUNGS: Clear. CARDIAC: Regular rate. No murmurs or rubs. EXTREMITIES: Left elbow is tender. He does not wish to move it at all. Shoulder and clavicle are within normal limits. Wrist is normal to inspection. He does have some pain to palpation. Hand has good capillary refill. He seems to have decreased sensation in all three dermatomes. He has moderately good abduction of all fingers. He has moderate opponens strength with his thumb. He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow. He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length. The proximal part looks like it is in good position. The distal part has about 6 mm of displacement. There is no significant angulation. The joint itself appears to be intact. The fracture line ends where it appears above the joint. I do not see any extra blood in the joint. I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X. He suggests we go ahead and splint him up and he will follow the patient up. At this point, it does not seem like there needs to be any surgical revision. The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied. There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go. Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with. They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1. Fracture of the humerus, spiral.,2. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3. Psychiatric disorder, unspecified.,DISPOSITION: The patient will follow up as mentioned above. They can return here anytime as needed.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 828
}
|
TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL: ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei. He was admitted for a left wound breakdown with drainage. He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit. It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia. The patient understood these risks and wished to proceed. The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic. He was placed in the right lateral decubitus, and all bony prominences were well padded. An axillary roll was placed. A well-padded thigh tourniquet was placed on the left leg. The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement. Left leg was then prepped and draped in usual sterile fashion. The previous five antibiotic spacer beads were removed without difficulty. The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone. The wound actually looked quite good with evidence of purulence or drainage. Skin edges appeared to be viable. Hardware all looked to be intact. At this point, the wound was irrigated with 9 liters of bibiotic solution. A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint. The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure. He was immediately available for any questions during the case.,PLAN:,1. A CAM walker boots.,2. A VAC change on Sunday by the nurse.,3. A flap per Plastic Surgery.surgery, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 829
}
|
PROCEDURE PERFORMED:,1. Right femoral artery access.,2. Selective right and left coronary angiogram.,3. Left heart catheterization.,4. Left ventriculogram.,INDICATIONS FOR PROCEDURE:, A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath. The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%. This was a sharp decline from a previous LVEF of 50% to 55%. We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state. The right groin was prepped and draped in the usual sterile manner. 2% Lidocaine was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery. 6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram. A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11. There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1. The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2. The left main coronary artery is free of any disease.,3. The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches. The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4. The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches. One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5. The left anterior descending artery has a patent stent in the proximal LAD. The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss. There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery. The diagonal branches are free of any disease.,6. The right coronary artery is a dominant vessel and has mild luminal irregularities. Its midsegment has a focal area of 30% narrowing as well. The rest of the right coronary artery is free of any disease.,7. The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy. Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram. The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.cardiovascular / pulmonary, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 830
}
|
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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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 831
}
|
PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE: ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped. Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route. This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg. The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventilation was commenced. The patient was fully warm and the patient was then wean from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well.cardiovascular / pulmonary, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 832
}
|
PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:, Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME: ,40 minutes at 325 mmHg.,POSITION:, Prone.,HISTORY OF PRESENT ILLNESS: ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:, After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff. While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient. The patient was then transferred to the operative table and placed in the prone position. All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time. Left lower extremity was sterilely prepped and draped in the usual sterile fashion. Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes. After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal. Careful dissection was then taken down to the level of the peritenon. Once this was reached, full thickness flaps were performed medially and laterally. Next, retractor was placed. All neurovascular structures were protected. A longitudinal incision was then made in the peritenon and opened up exposing the tendon. There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point. The plantar tendon was noted to be intact. The tendon was debrided at this time of hematoma as well as frayed tendon. Wound was copiously irrigated and dried. Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair. Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed. Two sutures were then used and tied individually ________ from the tendon. The tendon came together very well and with a tight connection. Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon. The wound was once again copiously irrigated and dried. A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin. Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position. At this time, the Department of anesthesia reversed the anesthetic. The patient was transferred back to hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure well. There were no complications.surgery, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 833
}
|
PHYSICAL EXAMINATION:, Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0. All other systems were normal.,PROCEDURES: ,Sextant biopsy of the prostate.,Radical prostatectomy: Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy: Right lobe, negative. Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy: Negative lymph nodes. Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right. Tumor overall involved less than 5% of the tissue. Surgical margin was reported and involved at the apex. The capsule and seminal vesicles were free.,DISCHARGE NOTE:, Patient has made good post-op recovery other than mild urgency incontinence. His post-op PSA is 0.1 mg/ml.soap / chart / progress notes, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 834
}
|
XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ 07018,Re:letters, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 835
}
|
TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.surgery, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 836
}
|
PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed.podiatry, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 837
}
|
TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left. The right side prepped and draped in the usual sterile fashion. Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and. The second just lateral to the umbilicus. Once this was clear, the Bactiseal catheter was then tunneled. This was connected to a Strata valve. The Strata valve was programmed to a setting of 1.01 and this was ensured. The small burr hole was then created. The area was then coagulated. Once this was completed, new Bactiseal catheter was then inserted. It was connected to the Strata valve. There was good distal flow. The distal end was then inserted into the peritoneal region via trocar. Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue. The right frontal incision was then opened. The Ommaya reservoir identified and removed. The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn. Once all the wounds were completed, dry sterile dressings were applied. The patient was then transported back to the ICU in stable condition intubated. Blood loss minimal. All sponge and needle counts were correct.surgery, ommaya reservoir, frontal, strata valve, intraventricular hemorrhage, vp shunt, ventriculoperitoneal, hydrocephalus,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 838
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GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.cardiovascular / pulmonary, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 839
}
|
DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL: The patient is alert, in no respiratory distress.,VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK: Supple.,CHEST: Clear breath sounds.,CARDIAC: Normal S1, S2 without murmur.,ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness.,SKIN: Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:, Regular as tolerated.,DISCHARGE MEDICATIONS: ,1. Ciprodex Otic Solution in the right ear twice daily.,2. Augmentin 500 mg three times daily x10 days.,FOLLOW UP: ,1. Dr. Y in one week (ENT).,2. The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 840
}
|
PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1. Radical retropubic prostatectomy, robotic assisted.,2. Bladder suspension.,ANESTHESIA:, General by intubation.,The patient understands his diagnosis, grade, stage and prognosis. He understands this procedure, options to it and potential benefits from it. He strongly wishes to proceed. He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE: ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion. My camera ports were then placed in the standard fan array. A camera port was placed in the midline above the umbilicus using the Hasson technique. The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision. My assistant was on the right. The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis. This nicely exposed the space of Retzius. I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally. The levator ani muscles were carefully dissected free from the prostate and pushed laterally. Dissection was continued posteriorly toward the bundles and caudally to the apex. The puboprostatic ligaments were then transected. A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck. The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound. I then transected the posterior bladder neck down to the level of the ampullae of the vas. The ampullae were mobilized and transected. These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized. Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply. Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles. I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water. Hemostasis was found to be complete. I then carried out a urethrovesical anastomosis. This was accomplished with 3-0 Monocryl ligatures. Two of these were tied together in the midline. They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied. A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation. The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension. This was done in hopes of obtaining early urinary control. This was accomplished with 0 Vicryl ligatures. One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis. This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision. A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk. The camera port fascia was closed with running 0 Vicryl. The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well. There were no complications. Sponge and instrument counts were reported correct at the end of the case.surgery, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 841
}
|
REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically.neurology, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 842
}
|
PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.surgery, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 843
}
|
PREOPERATIVE DIAGNOSIS:,1. Acute bowel obstruction.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1. Acute small bowel obstruction.,2. Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Release of small bowel obstruction.,3. Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:, None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY: ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction. Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia. There was a loop of small bowel incarcerated within the hernia sac. It showed signs of ecchymosis, however no signs of any ischemia or necrosis. It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family. The patient was brought to the operating suite. After general endotracheal intubation, prepped and draped in normal sterile fashion. A midline incision was made around the umbilical hernia defect with a #10 blade scalpel. Dissection was then carried down to the fascia. Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia. The abdomen was entered under direct visualization. The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis. The remaining of the fascia was then extended using Metzenbaum scissors. The hernia sac was removed using Mayo scissors and sent off as specimen. Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities. The small bowel was then milked down removing all the fluid. The bowel was decompressed distal to the obstruction. Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed. The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture. A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition.gastroenterology, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 844
}
|
PREOPERATIVE DIAGNOSIS:, 12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS: ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. The fetus of 12 week had been delivered previously by Dr. X in the ER.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS: ,None.,SPONGE AND NEEDLE COUNT: , Correct.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room placed in the operating table in supine position. After adequate anesthesia, the patient was placed in dorsal lithotomy position. The vagina was prepped. The patient was then draped. A speculum was placed in the vagina. Previously mentioned products of conception were teased out with a ring forceps. The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10-mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12-week pregnancy. A sharp curettage then was performed and followed by two repeat suction curettages. The procedure was then terminated and the equipment removed from the vagina, as well as the speculum. The patient tolerated the procedure well. Blood type is Rh negative. We will see the patient back in my office in 2 weeks.obstetrics / gynecology, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 845
}
|
PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion. Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly. The temporal artery was found and exposed in an extension of about 2 cm. The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology. Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion. A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm. This was also proximally and distally ligated with 6-0 Prolene and also side branch. Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well. Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.neurology, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 846
}
|
FINAL DIAGNOSES:,1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2. Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful. More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty. Blood loss was about 125 cc. Postop x-ray showed good alignment and positioning of the cages, plate, and screws. After surgery, he was able to slowly increase his activity level with assistance from physical therapy. He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. He also had some nausea with the PCA. He had a low-grade fever to 100.2 and was started on incentive spirometry. Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home. He has been counseled regarding wound care and has received a neck sheet for instruction. He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems.discharge summary, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,
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{
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PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:, Aqueductal stenosis.,TITLE OF PROCEDURE: ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:, Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION: ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION: ,Triventricular hydrocephalus most consistent with aqueductal stenosis. The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral. The right frontal area was shaven and then the head was prepped and draped in a standard routine manner. The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine. A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture. Two Weitlaner were used to hold the scalp open. A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated. Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated. CSF was collected for routine studies. We saw the total absence of __________ consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle. I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening. The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________ various motions. We went through the membrane of Liliequist. We could see the basilar artery and the clivus, and there was no significant bleeding from the edges. The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture. The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips. The patient tolerated the procedure well.surgery, aqueductal stenosis, ventriculostomy, triventricular hydrocephalus, neuropen, endoscopic third ventriculostomy, endotracheal tube anesthesia, burr hole port, aqueductal,
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{
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"dataset_name": "medical-transcription-40",
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CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY: ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable.,GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact.,NECK: No lymphadenopathy or JVD.,HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs.,LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi.,ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted.,GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES: No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:, Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.nan
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{
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CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision "greyed out" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were "unremarkable." Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly "unremarkable.",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: , ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or "gray outs" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.nan
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HISTORY:, The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation. These procedures were performed at Medical College Hospital. Family states that they moved to the United States. Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery. He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg. The QP:QS ratio of 0.6:1. A large decompressing venous collateral was also appreciated. The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta. A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful. Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein. Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire. This catheter then also advanced into the bridging innominate vein. The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava. A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery. There was no vascular continuity to the stump of the right Glenn. The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava. The Bernstein catheter was then reintroduced using a Terumo guidewire. Probing of the superior vena cava facilitated access into the right lower pulmonary artery. The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis. The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length. The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist. This facilitated advancement of a flexor sheath into the proximal portion of the stenosis. A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe. A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist. Angiogram demonstrated a good stent apposition to the caval wall. Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist. Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery. The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery. Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery. Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery. Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist. Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery. The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist. Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter. Repeat angiograms were then performed. Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein. A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter. An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein. Once stable device was confirmed, the device was released from the delivery catheter. The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein. A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION:, Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%. The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen. Remaining saturations reflected complete admixture. There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow. Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending, descending pressures were similar and normal. Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg. The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1. The pulmonary vascular resistance was elevated at 4.4 Woods units. Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg. Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation. There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg. There was an increase in arterial pressure. The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared. Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava. There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient. There was absence of contrast filling of the right middle and right upper pulmonary artery. Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow. Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES: ,1. Asplenia syndrome.,2. Dextrocardia bilateral superior vena cava.,3. Atrioventricular septal defect.,4. Total anomalous pulmonary venous return to the right-sided atrium.,5. Double outlet right ventricle with malposed great vessels.,6. Severe pulmonary stenosis.,7. Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Bilateral bidirectional Glenn shunt.,3. Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES: ,1. Obstructed right caval pulmonary anastomosis.,2. Obstructed right proximal pulmonary artery.,3. Venovenous collateral vessel.,CURRENT INTERVENTION: ,1. Balloon dilation of the right superior vena cava and stent implantation.,2. Balloon dilation of the proximal right pulmonary artery, stent implantation.,3. Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference. A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion. The patient will be maintained on anticoagulant medications of aspirin and Plavix. Further cardiology care will be directed by Dr. X.nan
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{
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SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food diary. I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern. I encouraged her to continue all of this.,ASSESSMENT:, The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. She needs to continue all this.,PLAN:, Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.diets and nutritions, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food
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{
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PREOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,PROCEDURE,1. Removal of cystic lesion, left posterior mandible.,2. Removal of teeth numbers 4, 13, 20, and 29.,3. Removal of teeth numbers 1 and 16.,4. Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome. Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position. Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures. The oral cavity was suctioned, was drained of fluid and a throat pack was placed. General anesthesia nursing service was notified and which was removed at the end of the procedure. Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL. A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth. Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt. Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle. Secondly, tooth number 4 was removed. Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side. Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9. This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion. These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure. Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar. The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle. This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin. Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure. Teeth number 20 and 29 where removed and 3-0 chromic suture placed. This concluded the procedure. All cottonoids and other sponges, throat pack were removed. No complications were encountered. The aforementioned cystic lesion was sent with specimen no drains were placed. The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.surgery, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth,
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{
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PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper extremity. She has difficulty with pushing and pulling and lifting with her right arm. She describes an intermittent tingling sensation in the volar aspect of her right hand. She states she has diminished grip strength in her right hand because of wrist pain complaints. She states that the Wellbutrin samples I had given her previously for depression seem to be helping. Her affect appears appropriate. She reports no suicidal ideation. She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints. She also takes Imitrex occasionally for headache complaints related to her neck pain. She also takes Flexeril occasionally for back spasms and Darvocet for pain. She is asking for a refill on some of her medications today. She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile. Blood pressure is 106/68, pulse of 64, respirations of 20. Her physical exam is unchanged from 03/21/05. Her orthopedic exam reveals full range of motion of the cervical spine. Cervical compression test is negative. Valsalva's maneuver is negative. Hoffmann's sign is negative. DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally. Her sensation is grossly intact to the upper extremity dermatomes. Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists. Passive range of motion of the right wrist is painful for her. Passive range of motion of the left wrist is non painful. Active range of motion of both wrists and hands are full. She is right hand dominant. Circumferential measurements were taken in her upper extremities. She is 11" in the right biceps, 10 1/2" in the left biceps. She is 9 3/4" in both right and left forearms. Circumferential measurements were also taken of the lower extremities. She is 21" at both the right and left thighs, 15" in both the right and left calves. Jamar dynamometry was assessed on three tries in this right-hand-dominant individual. She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand. , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12" from touching the floor. Lumbar extension is to 30 degrees. The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh. The left SLR is to 90 degrees without back pain. DTRs are +1 at the knees and ankles. Toes are downgoing to plantar reflexes bilaterally. Sensation is grossly intact in the lower extremity dermatomes. Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1) Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2) Cervical sprain/strain with myofascial dysfunction. (3) Thoracic sprain/strain with myofascial dysfunction. (4) Probable chronic tendonitis of the right wrist. She has negative nerve conduction studies of the right upper extremity. (5) Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory. I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:, I told the patient to continue her medication course per above. It seems to be helping with some of her pain complaints. I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms. I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04. , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager. She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground. She had onset of headaches and neck pain, and pain complaints about her right upper extremity. She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain. , ,FACTORS FOR DISABILITY:,OBJECTIVE: ,1. She exhibits decreased range of motion in the lumbar trunk.,2. She has an abnormal MRI revealing a disc herniation at L5-S1.,3. She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1. Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2. With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3. Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4. Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds. She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain. She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates. She also relates headaches, which she did not have prior to her industrial injury. , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient. It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort. The patient should probably no lift more than 15 to 20 pounds maximally. She should probably not repetitively bend or stoop. She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand. She should probably not lift more than 10 pounds repetitively with the right upper extremity. I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity. , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04. There does not appear to be any apportionable issues here.nan
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{
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"dataset_name": "medical-transcription-40",
"id": 854
}
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PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:, Subxiphoid pericardiotomy.,ANESTHESIA:, General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:, This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition.cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 855
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HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:, The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis. There were come concentric rings present. There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus. Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach are normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal. Adverse reactions: None.,FINAL IMPRESSION: ,Esophageal changes suggestive of eosinophilic esophagitis. Biopsies throughout the length of the esophagus were obtained for microscopic analysis. There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.gastroenterology, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 856
}
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PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1. DePuy Ultima calcar stem, size 3 x 45.,2. Bipolar head 28 x 43.,3. Head with +0 neck length.,4. Distal centralizer and cement restrictor.,5. SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS: ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter. The lesser trochanter was intact. The fracture site was noted to show abnormal pathological tissue with grayish discoloration. The quality of the bone was also pathologically abnormal with soft trabecular bone. The abnormal pathological tissues were sent along with the femoral head to pathology for assessment. Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture. She denied any history of fall or trauma. The presentation was consistent with pathological fracture pending tissue assessment. Indication, risks, and benefits were discussed. Treatment options were reviewed. No guarantees have been made or implied.,PROCEDURE: ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up. The left lower extremity was prepped and draped in a standard sterile fashion. Time-out procedure was called. Antibiotics were infused.,A standard posterolateral approach was made. Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus. This was then incised along the line of the incision. Hemostasis was achieved. Charnley retractor was positioned. The trochanter was intact. The gluteus medius was well protected with retractor. The piriformis and minimus junction was identified. The minimus was also reflected along with the medius. Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion. Similarly, L-shaped capsulotomy was performed. A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair. Fracture site was exposed. The femoral neck fracture was noted to be very low-lying basicervical type. Femoral head was retrieved without any difficulty with the help of a corkscrew. The head size was measured to be 43 mm. Bony fragments were removed. The acetabular socket was thoroughly irrigated. A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability. The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration. This was sent to the pathology. The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem. An L-shaped osteotomy was performed in order to accept the calcar prosthesis. The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter. There was no calcar superior to the lesser trochanter. The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis. Hemostasis was achieved. Now, the medullary canal was entered with a canal finder. The fracture site was well exposed. Satisfactory lateralization was performed. Attention was for the reaming process. Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal. At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted. Appropriate anteversion was positioned. The anteversion was marked with a Bovie to identify subsequent anteversion during implantation. The bony edges were trimmed. The calcar implant with 45 mm neck length was fit in the host femur very well. There was no evidence of any subsidence. At this point, trial reduction was performed using a bipolar trial head with 0 neck length. The relationship between the central femoral head and the greater trochanter was satisfactory. The hip was well reduced without any difficulty. The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory. The shuck was less than 1 mm. Leg length was satisfactory in reference to the contralateral leg. Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation. Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees. After verifying the stability and range of motion in all direction, trial components were removed. The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely. At this point, 2 batches of SmartSet cement with antibiotics were mixed. The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected. Centralizer was positioned. The cement restrictor was inserted. Retrograde cementing technique was applied once the canal was dried. Using cement gun, retrograde cementing was performed. The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured. The excess cement was removed with the help of a curette and Freer elevator. All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head. Once again, 0 neck length trial bipolar head was inserted over the trunnion. It was reduced and range of motion and stability was satisfactory. I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation. There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation. I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable. At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced. Range of motion and stability was as above. Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis. This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster. Satisfactory reinforcement was achieved with the #5 Ethibond. The wound was thoroughly irrigated. Hemostasis was achieved. The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl. The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures. Skin was approximated with staples. Sterile dressings were placed. Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noted.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 857
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PREOPERATIVE DIAGNOSIS: , Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct right inguinal hernia.,TITLE OF PROCEDURE: , Marlex repair of right inguinal hernia.,ANESTHESIA:, Spinal.,PROCEDURE IN DETAIL:, The patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic. The right inguinal region was shaved and prepped and draped in a routine sterile fashion. The patient received 1 gm of Ancef IV push.,Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue. The external oblique fascia was exposed and incised down to and through the external inguinal ring. The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal. The cord was surrounded with a Penrose drain. The hernia sac was separated from the cord structures. The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene. Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord. It was placed around the cord and sutured to itself with 2-0 Prolene. The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene. The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief. The cord was returned to its position. External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct. Sterile dressing was applied.urology, marlex repair, inguinal region, external oblique fascia, inguinal ring, direct right inguinal hernia, inguinal hernia, inguinal, repair, marlex, oblique, fascia, hernia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 858
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PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.surgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 859
}
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HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2. Biophysical profile (BPP) score 8/8.radiology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 860
}
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Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.,REST ECHO:, EF 60%. No wall motion abnormalities. EKG shows normal sinus rhythm with mild ST depressions. The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen. Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities. There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise. No dysrhythmias noted.,IMPRESSION:,1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2. Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient. Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 861
}
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PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them. The large and small bowels were completely enveloping a large right ovarian cystic mass. Normal anatomy was difficult to see due to adhesions. Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid. Cyst wall, tube, and ovary were stripped away from the bowel. Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube. There was excellent postoperative hemostasis.,PROCEDURE: ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty. She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion. A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision. Incision was carried down carefully until the peritoneal cavity was reached. Care was taken upon entry of the peritoneum to avoid injury of underlying structures. At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery. The omentum was carefully stripped away from the patient's right side developing a window. This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum. A large mass of bowel was noted to be adherent to itself causing a quite tortuous course. Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis. Excellent hemostasis was noted. The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst. Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst. Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured. Large amount of turbid fluid was noted and was evacuated. The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel. Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter. This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl. A suture ligature of #0 Vicryl was used to obtain hemostasis. Excellent hemostasis was noted at this pedicle. The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum. Care was taken at the side of the remnant of the uterine vessels. However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted. Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube. Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal. It was then left in situ. Hemostasis was achieved in the pelvis with the use of electrocautery. The abdomen and pelvis were copiously irrigated with warm saline solution. The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle. The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen. The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly. Excellent closure of the incision was noted. The subcutaneous tissues were then copiously irrigated. Hemostasis was achieved with the use of cautery. Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture. The skin was closed with staples.,Incision was sterilely clean and dressed. The patient was awakened from general anesthesia and taken to the recovery room in stable condition. All counts were noted correct times three.obstetrics / gynecology, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 862
}
|
OPERATIVE PROCEDURE:, Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:, Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina. Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings. The patient tolerated the procedure well. Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending. Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:, Pneumonia, infiltrates.surgery, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 863
}
|
PREOPERATIVE DIAGNOSIS:, Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:, Right undescended testicle.,OPERATIONS:,1. Right orchiopexy.,2. Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis. The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding. The testis was identified right at the external inguinal ring. The testis was unable to be brought down into the scrotal sac. The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown. Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed. Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed. The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in the inguinal and scrotal area. After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal. The incision came through the subcutaneous tissue and external oblique fascia was identified. The external oblique fascia was opened sharply and was taken all the way down towards the external ring. The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture. After dissecting proximally, the testis was identified in the distal end of the inguinal canal. The testis was pulled up. The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring. There was very small hernia, which was removed and was tied at the base. PDS suture was used to tie this hernia sac all the way up to the base. There was a Y right at the vas and cord indicating there was enough length into the scrotal sac. The testis was easily brought down into the scrotal sac. One centimeter superior scrotal incision was made and a Dartos pouch was created. The testicle was brought down into the pouch and was placed into the pouch. Careful attention was done to ensure that there was no torsion of the cord. The vas was medial all the way throughout and the cord was lateral all the way throughout. The epididymis was in the posterolateral location. The testicle was pexed using 4-0 Vicryl into the scrotal sac. Skin was closed using 5-0 Monocryl. The external oblique fascia was closed using 2-0 PDS. Attention was drawn to re-create the external inguinal ring. A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord. Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia. After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion. Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable. It was smaller than the other side, probably by 50%. There were no palpable testicular masses. Plan was for the patient to follow up with us in about 1 month. The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours. No tub bath for 2 months. The patient and family understood all the instructions.surgery, undescended testicle, orchiopexy & herniorrhaphy, external oblique fascia, inguinal ring, scrotal sac, oblique fascia, testicle, herniorrhaphy, orchiopexy, inguinal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 864
}
|
REFERRAL INDICATION,1. Tachybrady syndrome.,2. Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a single-chamber pacemaker.,2. Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME: ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Ancef 1 g.,2. Benadryl 50 mg.,3. Versed 3 mg.,4. Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death 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 a 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. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2. Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:, Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2. Chest x-ray to rule out pneumothorax and verify lead position.,3. Completion of course of antibiotics.,4. Device interrogation in the morning.,5. Home dismissal instructions provided in a written format.,6. Wound check in 7 to 10 days.,7. Enrollment in Device Clinic.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 865
}
|
SUBJECTIVE:, This is a 12-year-old male who comes in for healthy checkups and sports physical. No major concerns today. He is little bit congested at times. He has been told he is allergic to grasses. They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports. He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:, Otherwise, reviewed. Very healthy.,CURRENT MEDICATIONS:, Claritin p.r.n.,ALLERGIES TO MEDICINES:, None.,FAMILY SOCIAL HISTORY:, Everyone else is healthy at home currently.,DIETARY:, He is on whole milk and does a variety of foods. Growth chart is reviewed with mother. Voids and stools well.,DEVELOPMENTAL:, He is in seventh grade and going out for cross-country and track. He is supposed to be wearing glasses, is not today. We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother. His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General: A well-developed, well-nourished male in no acute distress.,Dermatologic: Without rash or lesion.,HEENT: Head normocephalic and atraumatic. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes are present bilaterally. Optic discs are sharp with normal vasculature. Ears: Tympanic membranes are gray, translucent with normal light reflex. Nares are very congested. Turbinates swollen and boggy.,Neck: Supple without masses.,Chest: Clear to auscultation and percussion, easy respirations. No accessory muscle use.,Cardiovascular: Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back: Symmetric with no scoliosis or kyphosis noted. Normal flexibility. Femoral pulses 2+ and symmetric.,Abdomen: Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam: Normal Tanner III male. Testes descended bilaterally. No abnormal rash, discharge, or scars.,Extremities: Pink and warm. Moves all extremities well with normal function and strength in the arms and legs. Normal balance, station, and gait. Normal speech.,Neurologic: Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:, Healthy Tanner III male, developing normally.,PLAN:,1. Diet, growth, safety, drugs, violence, and social competence all discussed.,2. Immunizations reviewed.,3. We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4. Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 866
}
|
CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE: ,Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.,FINDINGS:, Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. Degenerative disk and joint disease at C5-C6.,3. Retention cyst versus polyp of the right maxillary sinus.neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 867
}
|
PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:, Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. Preoperative antibiotics were given for prophylaxis against surgical infection. The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found. The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels. This was dissected back to the hernia opening. The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring. The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures. By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.urology, cremasteric muscle, pubic tubercle, external oblique aponeurosis, inguinal herniorrhaphy, inguinal hernia, cord structures, penrose drain, bovie electrocautery, inguinal, herniorrhaphy, metzenbaum, bovie, electrocautery, cord, hernia
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 868
}
|
DESCRIPTION OF PROCEDURE: , 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 sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.surgery, ophthalmic fashion, vitrectomy, operating, superonasally, 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": 869
}
|
SUBJECTIVE: ,This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. He has been taking Allegra-D intermittently, but he is almost out and he needs a refill. The second problem, his foot continues to breakout. It seems like it was getting a lot better and now it is bad again. He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream. I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence. He works in the flint and it is really hot where he works and it has been quite humid lately. The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger. He is interested in getting that frozen today. Apparently, he tells me I froze a previous wart on him in the past and it went away. Next, he is interested in getting some blood test done. He specifically mentions the blood test for his prostate, which I informed him is called the PSA. He is 50 years old now. He will also be getting his cholesterol checked again because he has a history of high cholesterol. He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking. He says it is difficult to quit. He tells me he did quit chewing tobacco. I told him to keep trying to quit smoking. ,REVIEW OF SYSTEMS:, General: With this illness he has had no problems with fever. HEENT: Some runny nose, more runny nose than congestion. Respiratory: Denies shortness of breath. Skin: He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today. At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16. General exam: The patient is nontoxic and in no acute distress. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing. Skin exam: I checked out the bottom of his right foot. He has peeling skin visible consistent with tinea pedis. On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart. The size of this wart is approximately 3 mm in diameter.,ASSESSMENT: ,1. Upper respiratory tract infection, persistent.,2. Tinea pedis.,3. Wart on the finger.,4. Hyperlipidemia.,5. Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D. I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day. I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work. His wart has been present for some time now and he would like to get it frozen. I offered him the liquid nitrogen treatment and he did agree to it. I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart. He tolerated the procedure very well. I froze it once and I allowed for a 3 mm freeze zone. I gave him verbal wound care instructions after the procedure. Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test. Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.general medicine, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 870
}
|
EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.neurology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 871
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|
PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.dermatology, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 872
}
|
IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance. According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile. The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police. On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder. The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup. Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed. The patient resides independently. The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION: ,Attitude: Suspicious, but cooperative.,Appearance: Shows appropriate hygiene and grooming.,Psychomotor Behavior: Within normal limits. No agitation or retardation. No EPS or TDS noted.,Affect: Labile.,Mood: Euphoric.,Speech: Pressured.,Thoughts: Disorganized.,Thought Content: Remarkable for grandiose delusions as noted. The patient denies auditory hallucinations.,Psychosis: Grandiose delusions as noted above.,Suicidal/Homicidal Ideation: The patient denies on admission.,Cognitive Assessment: Grossly intact. The patient is oriented x 3.,Judgment: Poor shown by noncompliance to the outpatient treatment.,Assets: Include stable physical status.,Limitations: Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I: BAD, manic with psychosis.,AXIS II: None.,AXIS III: None known.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely. The patient will be evaluated for more structural outpatient followup following stabilization.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 873
}
|
SUBJECTIVE:, The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP, which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:, She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight.soap / chart / progress notes, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 874
}
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REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY: ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:, Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY: ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT: Atraumatic.,NECK: Soft and supple.,LUNGS: Bilaterally diminished.,HEART: Regular.,ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:, Have her admitted to the medical service for treatment of her hyponatremia.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 875
}
|
REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested. The patient denies any chest pain or shortness of breath. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At this time, he is on:,1. Atrovent and albuterol nebulizers.,2. Azithromycin.,3. Potassium chloride 10 mEq p.o. daily.,4. Furosemide 20 mg IV daily.,5. Enoxaparin 40 mg daily.,6. Lisinopril 10 mg p.o. daily.,7. Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:, History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke. Drinks occasionally.,FAMILY HISTORY: ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea. He has cough. No fever. No abdominal pain. No syncope, near-syncope, or palpitation. All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable, not in distress.,VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT: Atraumatic, normocephalic. Eyes PERRLA.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Clear.,HEART: S1 and S2, regular. No S3. No S4. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,DIAGNOSTIC DATA:, EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay. CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. Loculated pleural effusion in the left upper lobe. No PE. Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05. White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1. Pneumonia.,2. Diastolic heart failure, not contributing to his present problem.,3. Hypertension, controlled.,4. History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics. No further cardiac workup at this time.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 876
}
|
HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.,PAST MEDICAL HISTORY:, The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:, She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL: The patient is an elderly frail white female in no distress. LUNGS: Clear. HEART: Sounds are regular. ABDOMEN: She has a protuberant abdomen. She has tenderness to palpation in the lumbosacral area. Sciatic notch tenderness is not present. Straight leg raise testing evokes back pain. NEUROLOGICAL: She is awake, alert, and oriented. Speech is intact. Comprehension is normal. Strength is intact in the upper extremities. She has giveaway strength in the lower extremities. Reflexes are diminished at the knees and ankles. Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture. A CT scan has shown some healing of this fracture. She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain. She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments. At this point, I believe the patient is a good candidate for L5 kyphoplasty. I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery. Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed. The patient understands the issues involved. She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.consult - history and phy., leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 877
}
|
EXAM: , Three views of the right ankle.,INDICATIONS: ,Pain.,FINDINGS: , Three views of the right ankle are obtained. There is no evidence of fractures or dislocations. No significant degenerative changes or destructive osseous lesions of the ankle are noted. There is a small plantar calcaneal spur. There is no significant surrounding soft tissue swelling.,IMPRESSION: ,Negative right ankle.orthopedic, three views, calcaneal, plantar, spur, osseous, ankle
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 878
}
|
CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand. 2) Hospitalized for an unknown "nervous" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: "normal" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.neurology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 879
}
|
PREOPERATIVE DIAGNOSES:,1. Hematochezia.,2. Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Colonic polyps at 35 cm and 15 cm.,2. Diverticulosis coli.,2. Acute and chronic gastritis.,PROCEDURE PERFORMED:,1. Colonoscopy to cecum with snare polypectomy.,2. Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURES: ,This is a 43-year-old white male who presents as an outpatient to the General Surgery Service with hematochezia with no explainable source at the anal verge. He also had refractory dyspepsia despite b.i.d., Nexium therapy. The patient does use alcohol and tobacco. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of colonoscopy, the entire length of colon was visualized. The patient was found to have a sigmoid diverticulosis. He also was found to have some colonic polyps at 35 cm and 15 cm. The polyps were large enough to be treated with snare cautery technique. The polyps were achieved and submitted to pathology. EGD did confirm acute and chronic gastritis. The biopsies were performed for H&E and CLO testing. The patient had no evidence of distal esophagitis or ulcers. No mass lesions were seen.,PROCEDURE: ,The patient was taken to the Endoscopy Suite with the heart and lungs examination unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient was placed in the left lateral position where intravenous Demerol and Versed were given in a titrated fashion.,The video Olympus colonoscope was advanced per anus and without difficulty to the level of cecum. Photographic documentation of the diverticulosis and polyps were obtained. The patient's polyps were removed in a similar fashion, each removed with snare cautery. The polyps were encircled at their stalk. Increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized. Good blanching was seen. The polyp was retrieved with the suction port of the scope. The patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site. Diverticulosis coli was also noted. With colonoscopy completed, the patient was then turned for EGD. The oropharynx was previously anesthetized with Cetacaine spray and a biteblock was placed. Video Olympus GIF gastroscope model was inserted per os and advanced without difficulty through the hypopharynx. The esophagus revealed a GE junction at 39 cm. The GE junction was grossly within normal limits. The stomach was entered and distended with air. Acute and chronic gastritis features as stated were appreciated. The pylorus was traversed with normal duodenum. The stomach was again reentered. Retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia. There were no ulcers or mass lesions seen. The patient had biopsy performed of the antrum for H&E and CLO testing. There was no evidence of untoward bleeding at biopsy sites. Insufflated air was removed with withdrawal of the scope. The patient will be placed on a reflux diet, given instruction and information on Nexium usage. Additional recommendations will follow pending biopsy results. He is to also abstain from alcohol and tobacco. He will require follow-up colonoscopy again in three years for polyp disease.surgery, endoscopy, olympus colonoscope, snare polypectomy, ge junction, refractory dyspepsia, colonic polyps, diverticulosis coli, chronic gastritis, esophagogastroduodenoscopy, snare, biopsies, dyspepsia, gastritis, diverticulosis, polypectomy, colonoscopy, hematochezia, polyps
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 880
}
|
CHIEF COMPLAINT:, Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.urology, bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 881
}
|
PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema, hemorrhages or exudates with normal vessels. ,EARS: , The ear canals are patent without edema, exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact. ,NOSE:, Without deformity, bleeding or discharge. No septal hematoma is noted. ,ORAL CAVITY:, No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard. ,NECK: , No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline. ,CHEST: , Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest. ,LUNGS: ,Clear to auscultation bilaterally. No rales, rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields. ,HEART:, Regular rate and rhythm. No murmur. No S3, S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal. ,ABDOMEN: ,Soft, nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted. ,RECTAL:, Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative. ,GENITOURINARY:, Penis is normal without lesion or urethral discharge. Scrotum is without edema. The testes are descended bilaterally. No masses are palpated. There is no tenderness. ,EXTREMITIES: , No clubbing, cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted. ,SKIN: , No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia, bulla or ecchymosis. ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen. ,PSYCHIATRIC: ,The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal.,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 882
}
|
PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage. A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures. The patient was agreeable to proceed.,OPERATIVE PROCEDURE: ,The patient was prepped and draped at the bedside over both chest tube sites. The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures. The skin was then cleansed and Vaseline occlusive dressing was applied over the sites. The same procedure was performed on the other side. The chest tubes were removed on full inspiration. Vital signs remained stable throughout the procedure. The patient will remain in the intensive care unit for continued monitoring.,cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 883
}
|
PREOPERATIVE DIAGNOSES:,1. Entropion, left upper lid.,2. Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room and prepped and draped in the usual fashion. The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness. The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place. An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised. Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade. Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery. An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure. Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied. No patch was applied to the left eye. The patient tolerated the procedure well and was sent to recovery room in good condition.ophthalmology, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 884
}
|
REASON FOR THE CONSULT:, Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer. There is a concern that the patient had a low-grade fever of 100.2 early this morning. The patient otherwise feels well. He was not even aware of the fever. He does have some ankle pain, worse on the right than the left. Old medical records were reviewed. He has multiple hospitalizations for leg cellulitis. Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past. Klebsiella and Enterobacter have also grown in the few wound cultures at some point. The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No malaise. Positive recent low-grade fevers. No chills.,HEENT: No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion. No sore throat.,CARDIAC: No chest pain or cough.,GASTROINTESTINAL: No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY: ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago. He is also a former cigarette smoker, quit several years ago.,ALLERGIES:, None known.,CURRENT MEDICATIONS:, Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS: Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE: The patient is awake, alert, and not in cardiorespiratory distress. Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES: Pink conjunctivae, anicteric sclerae. Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.,NECK: No palpable neck masses. Thyroid is not enlarged on inspection.,RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.,CARDIOVASCULAR: Regular cardiac rhythm. No thrills or rubs.,GASTROINTESTINAL: Normoactive bowel sounds. Soft. No guarding or rigidity.,LYMPHATIC: No cervical lymphadenopathy.,MUSCULOSKELETAL: Good range of motion of upper and lower extremities.,SKIN: There is hyperpigmentation involving the distal calf of both legs. There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage. Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg. There is warmth, but minimal tenderness on palpation of this area. There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm. Wound edges are poorly defined.,PSYCHIATRIC: Appropriate mood and affect, oriented x3. Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000. BUN and creatinine 9.2/0.52. Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6. One wound culture from right leg wound culture from 01/27/09 noted with young growth. Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:, Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus. No absolute findings.,IMPRESSION:,1. Fevers.,2. Right leg/ankle cellulitis.,3. Chronic recurrent bilateral ankle venous ulcers.,4. Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5. Hypertension.,RECOMMENDATIONS:,1. We have ordered 2 sets of blood cultures.,2. Agree with daptomycin and Primaxin IV.,3. Follow up result of wound cultures.,4. I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 885
}
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PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye. She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL: ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart. They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established. MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops. The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia. The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome. A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome. The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves. Each half was further subdivided with chopping and removed with phacoemulsification. The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece. The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty. The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS. The corneal wounds were hydrated and verified to be water-tight. Antibiotic ointment was placed, followed by a patch and shield. The patient was transported to the PACU in good/stable condition. There were no complications. Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.ophthalmology, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, surgery, chamber, phacoemulsification, extraction, visually, anterior, lens
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 886
}
|
CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 887
}
|
NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 888
}
|
REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure. The patient also has a very extensive cardiac history that would be outlined below. He is being admitted with worsening shortness of breath and constipation. He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1. Benign prostatic hypertrophy.,2. Peptic ulcer disease.,3. Atrial fibrillation.,4. Coronary artery disease.,5. Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6. ICD implantation.,7. Peripheral vascular disease.,8. CABG in 1991 and 1998.,9. Congestive heart failure, EF 40%.,10. Asbestos exposure.,MEDICATIONS,1. Coumadin 6 mg alternating with 9 mg.,2. Prevacid 30 mg once a day.,3. Diovan 160 mg every day.,4. Flomax 0.4 mg every day.,5. Coreg 25 mg in the morning and 12.5 mg at night.,6. Aldactone 25 mg a day.,7. Lasix 20 mg a day.,8. Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL: The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS: Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT: Significant for peripheral cyanosis.,NECK: Supple.,LUNGS: Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR: Regular rate and rhythm with murmur and metallic click.,ABDOMEN: Soft and benign.,EXTREMITIES: 1+ cyanosis. No clubbing. No edema.,LABORATORY DATA:, Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000. CK 266, PTT 37, PT 34, and INR 3.7. Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1. Hemoptysis.,2. Acute bronchitis.,3. Coagulopathy.,4. Asbestos exposure.,5. Left pleural effusion.,RECOMMENDATIONS,1. Antibiotics.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 889
}
|
PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:, ***,SKIN: ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:, The sclerae were anicteric and conjunctivae were pink and moist. Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. External inspection of the ears and nose showed no scars, lesions, or masses. Lips, teeth, and gums showed normal mucosa. The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,NECK: ,Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt.,CHEST: , Normal AP diameter and normal contour without any kyphoscoliosis.,LUNGS: , Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,CARDIOVASCULAR: ,There was a regular rate and rhythm without any murmurs, gallops, rubs. The carotid pulses were normal and 2+ bilaterally without bruits. Peripheral pulses were 2+ and symmetric.,ABDOMEN: ,Soft and nontender with normal bowel sounds. The liver span was approximately 5-6 cm in the right midclavicular line by percussion. The liver edge was nontender. The spleen was not palpable. There were no inguinal or umbilical hernias noted. No ascites was noted.,RECTAL: ,Normal perineal exam. Sphincter tone was normal. There was no external hemorrhoids or rectal masses. Stool Hemoccult was negative. The prostate was normal size without any nodules appreciated (men only).,LYMPH NODES: , No lymphadenopathy was appreciated in the neck, axillae or groin.,MUSCULOSKELETAL: , Gait was normal. There was no tenderness or effusions noted. Muscle strength and tone were normal.,EXTREMITIES: , No cyanosis, clubbing or edema.,NEUROLOGIC: ,Alert and oriented x 3. Normal affect. Gait was normal. Normal deep tendon reflexes with no pathological reflexes. Sensation to touch was normal.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 890
}
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PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS: ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size. There were no adnexal masses appreciated. The vulva and perineum appeared normal. Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally. There was a functional cyst on the left ovary. There was filmy adhesion in the left pelvic sidewall. There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac. The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis. The liver was visualized and appeared normal. The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization. She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia. She was then prepped and draped and placed in the dorsal lithotomy position. A bimanual exam was performed and the above findings were noted. Prior to beginning the procedure, her bladder was drained with a red Robinson catheter. A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum. The cervix was dilated so that the uterine elevator could be placed. Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made. The Veress needle was then inserted and using sterile saline ______ the pelvic cavity. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope. A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty. Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube. A second Hulka clip was then placed across the entire diameter just proximal to this. There was good hemostasis at the fallopian tube. The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle. A second Hulka clip was placed just distal to this again across the entire diameter. Good hemostasis was obtained. At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic. The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed. The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl. The suprapubic incision was then closed with Steri-Strips. The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic. The patient tolerated that procedure well. The sponge, lap, and needle counts were correct x2. She will follow up postoperatively for followup care.surgery, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 891
}
|
GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:, Clear to auscultation.,HEART:, Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.,ABDOMEN:, Soft with bowel sounds present. No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC: ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.office notes, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 892
}
|
ADMISSION DIAGNOSES:,1. Pneumonia, likely secondary to aspiration.,2. Chronic obstructive pulmonary disease (COPD) exacerbation.,3. Systemic inflammatory response syndrome.,4. Hyperglycemia.,DISCHARGE DIAGNOSES:,1. Aspiration pneumonia.,2. Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3. Chronic obstructive pulmonary disease (COPD) exacerbation.,4. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5. Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,7. Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8. Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9. Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10. Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11. Hyperlipidemia.,12. Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:, Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath. The patient received 3 nebulizers at home without much improvement. He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE: ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation. The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s. The patient subsequently received diltiazem, also received p.o. digoxin. The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn. The patient made slow, but steady improvement over the course of his hospitalization. The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed. The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula. The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet. Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time. The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged. There was also more pronounced patchy alveolar opacity, which appeared to be, "mass like" in the right suprahilar region. This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization. On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally. This was compared with an examination performed 3 days prior. The patient also had minimal bilateral effusions. The patient will continue with clindamycin for the next 2 weeks after discharge. Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center. The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay. The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1. Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2. Ativan 1 mg p.o. t.i.d.,3. Metformin 1000 mg p.o. b.i.d.,4. Glucotrol 5 mg p.o. daily.,5. Spiriva 1 puff b.i.d.,6. Lantus 25 units subcu q.a.m.,7. Cardizem CD 180 mg p.o. q.a.m.,8. Advair 250/50 mcg, 1 puff b.i.d. The patient is instructed to rinse with mouthwash after each use.,9. Iron 325 mg p.o. b.i.d.,10. Aspirin 325 mg p.o. daily.,11. Lipitor 10 mg p.o. bedtime.,12. Digoxin 0.25 mg p.o. daily.,13. Lisinopril 20 mg p.o. q.a.m.,14. DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15. Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given. No refills.,16. Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail. He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment. Note that this patient did not have community-acquired pneumonia. His discharge diagnosis is aspiration pneumonia. The patient will continue with a dysphagia 2 diet with thin liquids after discharge. The patient discharged with home health. A dietary and speech therapy evaluation has been ordered. Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.nan
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"dataset_name": "medical-transcription-40",
"id": 893
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PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was prepped and draped in the usual fashion. A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade. This was beveled anteriorly in a lamellar fashion using the crescent knife. Then the anterior chamber was entered with a slit knife. The chamber was deepened with Viscoat. Then a paracentesis at the 3 o'clock position was created using a super sharp blade. A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps. Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves. Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified. I/A proceeded without difficulty using the irrigation/aspiration cannula. The capsule was felt to be clear and intact. The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded. A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture. Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally. Maxitrol ointment was instilled into the conjunctival sac. The eye was covered with a double patch and shield, and the patient was discharged.surgery, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens
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{
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"dataset_name": "medical-transcription-40",
"id": 894
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PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day.surgery
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 895
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ADMISSION DIAGNOSIS: ,Adenocarcinoma of the prostate.,HISTORY:, The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5). The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion. He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:, Atrial fibrillation.,MEDICATIONS:, Coumadin and lisinopril.,SOCIAL HISTORY: ,Smokes none. Alcohol none.,ALLERGIES:, NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills. Eyes: No change in vision or diplopia. Ears: No tinnitus or vertigo. Mouth: No dysphagia. Pulmonary: No chronic cough or shortness of breath. Cardiac: No angina or palpitations. GI: No nausea, vomiting, diarrhea or constipation. Musculoskeletal: No arthritides or myalgias. Hematopoietic: No easy bleeding or bruising. Skin: No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL: The patient is well developed and well nourished.,HEENT: Head is normocephalic. Eyes, pupils are equal. Conjunctivae are pink. Sclerae are anicteric.,NECK: There is no adenopathy.,PULMONARY: Respirations are unlabored.,HEART: Regular rhythm.,ABDOMEN: Liver, spleen, kidney, and bladder are not palpable. There are no discernible masses. There are no peritoneal signs.,GENITALIA: The penis has no plaques. Meatus is on the glans. Scrotal skin is healthy. Testicles are fair consistency. Epididymides are nontender.,RECTAL: The prostate is +1 to 2/4. There are no areas that are suspicious for tumor. Consistency is even. Sidewalls are sharp. Seminal vesicles are not palpable.,MUSCULOSKELETAL: The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC: There are no gross focal neurologic abnormalities.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery. He has _________ surviving prostate cancer by Dr. Y. He is aware of incontinency, both total and partial. We discussed erectile dysfunction. We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death. He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely. He had no questions at the conclusion of our last conversation.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_40",
"dataset_name": "medical-transcription-40",
"id": 896
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PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA: ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation in OP position. Normal uterus, tubes and ovaries are noted. Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes. Normal uterus, tubes and ovaries were noted.,INDICATIONS: ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery. The patient was admitted and cervix was found to be 1 cm dilated. Pitocin augmentation of labor was started. The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me. At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest. Vaginal exam was done. Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations. At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section. Clock in the operating room is noted to be 2 minutes faster then the time on trace view. The OR delivery time was 19:36. Delivery of this infant was performed in 14 minutes from the onset of the deceleration. Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s. Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt. 2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine. As the incision site was being injected, the anesthesiologist arrived. The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique. The rectus muscles were separated in midline. The peritoneum was bluntly dissected. The bladder blade was inserted. The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction. The infant was subsequently delivered. Immediately following delivery of the infant. The infant was noted to be crying with good tones. The cord was clammed and cut. The infant was subsequently transferred or handed to the nursery nurse. The placenta was delivered manually intact with a three-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic sutures. Hemostasis was visualized. The uterus was returned to the abdomen. The pelvis was copiously irrigated. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was reapproximated with 0 Vicryl suture. The subcutaneous layer was closed with 2-0 plain gut. The skin was closed in the subcuticular stitch using 4-0 Monocryl. Steri-strips were applied. Sponge, laps, and instrument counts were correct. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.surgery, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,
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"dataset_name": "medical-transcription-40",
"id": 897
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HISTORY OF PRESENT ILLNESS:, This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney. His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable. He denies any chest pain or tightness in his chest. He denies any shortness of breath, nausea, or vomiting. He denies any change to his appetite. He denies any fevers, chills, dysuria, or hematuria. He does report his blood pressure being checked at the senior center and reporting that it is improved. The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,nan
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{
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"dataset_name": "medical-transcription-40",
"id": 898
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As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having "overactive bladder", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could "barely walk". She felt as if her balance is impaired and she felt as if she were "walking on stilts". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to "look better". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished 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: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements.nan
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REASON FOR REFERRAL:, The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,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 was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day. He has no recollection of the event. The following information is obtained from his medical record. On 09/29/09, he reportedly went to a five-hour meeting and stated several times "I do not feel well" and looked "glazed." He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual. She thought he was warm and had chills. He later returned to his baseline. He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline. His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination. Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing. Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room. The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours. He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous. He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline. He thought that his memory abilities were similar to those of his peers of his same age. When I asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time." He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time. So, The patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it. However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems. He denied any missed appointments, any difficulty scheduling and maintaining appointments. He does not have to recheck information for errors. He is able to complete tasks in the same amount of time as he always has. He reported that he has not made additional errors in tasks that he completed. He said he does write everything down, but has always done things that way. He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes. He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age. He remains completely independent in his ADLs. He denied any difficulty with driving or maintaining any activities that he had always participated in. He is also able to handle their finances. He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:, Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener. Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well. The patient reported drinking an occasional glass of wine approximately two days of the week. He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer. He denied any illicit drug use. Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma. He also had right carpal tunnel surgery in 2005 and has cholelithiasis. Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007. No evidence of acute intracranial processes identified. CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy. EEG was negative. Deferential diagnosis was transient global amnesia versus possible seizure disorder. Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disease and passed away at the age of 75. He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:, The patient obtained a law degree from the University of Baltimore. He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time. He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar. He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously. He reported that he repeated math classes "every year of school" and attended summer school every year due to that. He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country. He served also in the U.S. Coast Guard between 1951 and 1953. He has been married for the past 36 years to his wife, Linda, who is a homemaker. They have four children and he reported having good relationship with them. He described being very active. He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,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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