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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1300
}
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REASON FOR REFERRAL:, Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1301
}
|
CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS: ,1. Lovenox 60 mg subcutaneously q.12h. initiated.,2. Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3. Protonix 40 mg intravenous (IV) daily.,4. Vicodin p.r.n.,5. Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY: ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY: ,Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY: ,The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION: ,GENERAL: Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN: Mild facial acne.,HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS: Clear to auscultation with an occasional productive cough.,ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA: ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal.,ASSESSMENT: , 1. Newly diagnosed high-risk acute lymphoblastic leukemia.,2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3. Probable chronic left epididymitis.,PLAN: , 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3. Ultrasound/Doppler of the testicles.,4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1302
}
|
CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:, Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage.,PAST SURGICAL HISTORY:, IVC filter placement 1999.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1303
}
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PROBLEM LIST:,1. Acquired hypothyroidism.,2. Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3. Diabetes mellitus.,4. Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1. Levothyroxine 125 micrograms p.o. once daily.,2. CPAP.,3. Glucotrol.,4. Avandamet.,5. Synthroid.,6. Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI. She is not reporting polyuria, polydipsia or polyphagia. She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea. She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL: She is an overweight, very pleasant woman, in no acute distress. VITAL SIGNS: Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg. NECK: Reveals well healed surgical scar in the anteroinferior aspect of the neck. There is no palpable thyroid tissue noted on this examination today. There is no lymphadenopathy. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 is auscultated. EXTREMITIES: Deep tendon reflexes 2+/4 without a delayed relaxation phase. No fine resting tremor of the outstretched upper extremity. SKIN, HAIR, AND NAILS: All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following: Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1. Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2. Plan to continue following thyroglobulin levels.,3. Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4. Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5. Plan today is to repeat her thyroid function studies. This case was discussed with Dr. X and the recommendation. We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less. Therefore, labs have been drawn. We plan to see the patient back in approximately 6 months or sooner. A repeat body scan will not been done, the one in 03/06 was negative.endocrinology, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1304
}
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PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood.surgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1305
}
|
PREOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,PROCEDURE:, Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia. He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency. He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury. His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy. The images were brought up on the electronic imaging and confirmed that this was a left-sided condition. He was fixed in a three-point headrest. His scalp was shaved and prepared with Betadine, iodine and alcohol. We made a small curved incision over the temporal, parietal, frontal region. The scalp was reflected. A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created. After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain. The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up. We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline. After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline. We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates. The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment. Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this. I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.neurosurgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1306
}
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PROBLEMS LIST:,1. Type 1 diabetes mellitus, insulin pump requiring.,2. Chronic kidney disease, stage III.,3. Sweet syndrome.,4. Hypertension.,5. Dyslipidemia.,6. Osteoporosis.,7. Anemia.,8. A 25-hydroxy-vitamin D deficiency.,9. Peripheral neuropathy manifested by insensate feet.,10. Hypothyroidism.,11. Diabetic retinopathy.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management. Her last visit to this clinic was approximately three months ago. Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses. She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management. Her 14-day average is 191. She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low. She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100. She was able to manage this completely on her own. In the meantime, she is not having any other medical problems that have interfered with glucose control. Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.,CURRENT MEDICATIONS:,1. A number of topical creams for her rash.,2. Hydroxyzine 25 mg 4 times a day.,3. Claritin 5 mg a day.,4. Fluoxetine 20 mg a day.,5. Ergocalciferol 800 international units a day.,6. Protonix 40 mg a day.,7. Iron sulfate 1.2 cc every day.,8. Actonel 35 mg once a week.,9. Zantac 150 mg daily.,10. Calcium carbonate 500 mg 3 times a day.,11. NovoLog insulin via insulin pump about 30 units of insulin daily.,12. Zocor 40 mg a day.,13. Valsartan 80 mg daily.,14. Amlodipine 5 mg a day.,15. Plavix 75 mg a day.,16. Aspirin 81 mg a day.,17. Lasix 20 mg a day.,18. Levothyroxine 75 micrograms a day.,REVIEW OF SYSTEMS: , Really not much change. Her upper respiratory symptoms have resolved. She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain. She is not having any decreased appetite. She is not having painful urination, any blood in the urine, frequency or hesitancy. She is not having polyuria, polydipsia or polyphagia. Her visual acuity has declined, but she does not appear to have any acute change.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds. HEENT: Examination found her to be atraumatic and normocephalic. She has pupils that are equal, round, and reactive to light. Extraocular muscles intact. Sclerae and conjunctivae are clear. The paranasal sinuses are nontender. The nose is patent. The external auditory canal and tympanic membranes are clear A.U. Oral cavity and oropharynx examination is free of lesions. The mucosus membranes are moist. NECK: Supple. There is no lymphadenopathy. There is no thyromegaly. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. EXTREMITIES: Reveal no edema and is otherwise deferred.,ASSESSMENT AND PLAN: , This is a return visit to the renal clinic for the patient with history as noted above. She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following: Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour. Her target pre-meal is 120 and bedtime is 150. Her insulin/carbohydrate ratio is 10 and her correction factor is 60. We are not going to make any changes to her insulin pump settings at this time. I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night. She has agreed to try that and cut back on this a little bit. I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump. She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time. Nonetheless, she is out of warranty and we will try to get her a new pump.,Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1307
}
|
PREOPERATIVE DIAGNOSES:,1. Medial meniscal tear, posterior horn of left knee.,2. Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3. Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1. Carpal tunnel syndrome, right hand, severe.,2. Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3. Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1. Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2. Right carpal tunnel release.,3. Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS: ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems. He failed nonoperative management. We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table. After adequate induction of general anesthesia, he was placed in the left lateral decubitus position. All bony prominences were padded. The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum. Subacromial space was entered. Visualization was poor due to the hemorrhagic bursitis, and this was resected back. It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur. Rotator cuff was little bit fray, but otherwise intact. Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed. The burr was then introduced to the anterior portal and the distal clavicle excision carried out. The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well. The shoulder was then copiously irrigated, drained free of any residual debris. The wound was closed with 3-0 Prolene. Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes. Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis. Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis. The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down. The patient tolerated this portion of the procedure very well. The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars. After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus. These were resected back to the stable surface using a basket forceps and full-radius shaver. There was no evidence of any other significant arthritis in the knee. There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1308
}
|
PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2. Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint. The patient states she has had worsening bunion deformity for as long as she could not remember. She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal. 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 field. The stockinette was reflected, the foot was cleansed with a wet and dry sponge. Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. Care was taken to preserve the extensor digitorum longus tendon. The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone. Capsule and periosteum was reflected off the first metatarsal head. At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage. There was noted to be a prominent medial eminence. Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release. The abductor tendon attachments were identified and transected. The lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw. Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm. The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal. The first metatarsal cuneiform joint was identified. A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface. This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy. The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial. The osteotomy site was then feathered and tilted with tight estimation of the bony edges. The cortical hinge was maintained. A 0.27 x 24 mm screw was then inserted in a standard AO fashion. At this time, there was noted to be tight compression of the osteotomy site. A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted. The ________ angle was noted to be significantly released. Reciprocating rasp was then used to smoothen any remaining sharp edges. The 0.45 k-wire was removed. The foot was loaded and was noted to fill the remaining abduction of the hallux. At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm. The incision was then deepened down to the level of capsule over the base of the proximal phalanx. Again care was taken to preserve the extensor digitorum longus tendon. The capsule was reflected off of the base of the proximal phalanx. An Akin osteotomy was performed with the apex being lateral and the base being medial. After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site. Care was taken to preserve the lateral hinge. At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire. The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted. The remaining edge of the wire was then buried in the medial most distal drill hole. The area was then inspected and the foot was noted with significant reduction of the bunion deformity. The area was then flushed with copious amounts of sterile saline. Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site. A running #5-0 subcuticular stitch was then performed. Steri-Strips were applied. Total of 1 cc dexamethasone phosphate was then injected into the surgical site. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot. The patient was given postoperative instructions to be strictly nonweightbearing on the left foot. The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d. The patient is to follow-up with Dr. X in his office in four to five days as directed.surgery, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1309
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PREOPERATIVE DIAGNOSES: ,1. Congenital chylous ascites and chylothorax.,2. Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION: ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites. The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces. Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically. However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen. Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole. This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease. We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS: ,The patient's abdomen was relatively soft, minimally distended. Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity. What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon. It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery. There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option. Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive. They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery. They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well. No other major retroperitoneal structure or correctable structure was identified. Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION: ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow. We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above. Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia. As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described. The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites. The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems. Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option. We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath. Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well. He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak. The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.gastroenterology, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1310
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PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Sigmoid and left colon diverticulosis.,2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. If there is further bleeding, a full colonoscopy is recommended.surgery, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1311
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PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED: ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:, This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. It appears to be right down to the bone. MRI shows findings suggestive of osteomyelitis. The patient is being brought to operating room for debridement of this ulcer. Procedure, indication, and risks were explained to the patient. Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped. Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer. This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base. The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone. The deeper portion of the excised tissue was also sent for tissue cultures. Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix. Sterile dressing was applied. The patient transferred to recovery room in stable condition.surgery, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1312
}
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PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1. Wound debridement x2, including skin, subcutaneous, and muscle.,2. Insertion of tissue expander to the medial wound.,3. Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA: ,General.,INDICATIONS: , This patient developed a compartment syndrome. She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg. She was doing very well and was obviously improving.,The swelling was reduced. A compartment pressure had obviously improved based on examination. She was therefore indicated for placement of tissue expander for ventral wound closure. The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well. Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood them well. All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:, The patient was placed on the operating table and general anesthesia was achieved. The medial wound was noted to be approximately 10.5 cm in length x 4 cm. The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width. Both wounds were then thoroughly debrided. The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion. This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides. At this point adequate debridement was performed and healthy tissue did appear to be present. Initially on the medial wound I did place the DermaClose RC continuous external tissue expander. On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately. I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor. I then did place adequate tension on the sutures. Continued tension will be noted after engaging the tension controller. At this point I performed the similar procedure to the lateral wound. The skin anchors were placed separately and appropriately on either side of the skin margin. The line loop from the tension controller was placed in lace like manner through the skin anchors. The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained. Adequate tension was placed in this region. A non thick dressing was then applied to the open-wound region and sterile dressing was then applied. No complications were encountered throughout the procedure and the patient tolerated the procedure well. The patient was taken to recovery room in stable condition.orthopedic, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1313
}
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PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type.neurosurgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1314
}
|
HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2. Consider cardiology consult and further evaluation if clinically indicated.,3. Full report was sent to the PACS. Report will be mailed to Dr. ABC.radiology, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1315
}
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PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. He was placed into a well-molded splint after reduction was performed in the emergency department. Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure. The right upper extremity was prepped and draped in a sterile fashion. A 5-cm incision was made over the flexor carpi radialis of the right wrist. The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. Next, a reduction was performed placing the distal fragment into appropriate alignment. This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. An Acumed Accu-lock plate was placed along the volar aspect of the distal radius. This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment. A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. Two distal locking screws were placed along the plate itself. The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. AP and lateral views were taken of these screw placements again. None of these screws were into the joint and all had appropriate length into the dorsal cortex. Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. Bicortical purchase was appreciated and no screws were placed into the joint. The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.orthopedic, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1316
}
|
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_4",
"dataset_name": "medical-transcription-4",
"id": 1317
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ADENOIDECTOMY,PROCEDURE:, The patient was brought into the operating room suite, anesthesia administered via endotracheal tube. Following this the patient was draped in standard fashion. The Crowe-Davis mouth gag was inserted in the oral cavity. The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril. Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer. The adenoid pad was removed without difficulty. The nasopharynx was packed. Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated. The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.surgery, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1318
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SUBJECTIVE:, The patient returns today for a followup. She was recently in the hospital and was found to be septic from nephrolithiasis. This was all treated. She did require a stent in the left ureter. Dr. XYZ took care of this. She had a stone, which was treated with lithotripsy. She is now back here for followup. I had written out all of her medications with their dose and schedule on a progress sheet. I had given her instructions regarding follow up here and follow with Dr. F. Unfortunately, that piece of paper was lost. Somehow between the hospital and home she lost it and has not been able to find it. She has no followup appointment with Dr. F. The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc. Later she apparently found the prescriptions and they were filled. She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take. She had no clue as to seeing Dr. XYZ again. She says she is still not feeling very well and feels somewhat sick like. She has no clue as to still having a ureteral stent. I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:, As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:, She says she is voiding okay. She denies fever, chills, or sweats.,OBJECTIVE:,General: She was able to get up on the table by herself although she is quite unstable.,Vital Signs: Blood pressure was okay at about 120/70 by me.,Neck: Supple.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft.,Extremities: There is no edema.,IMPRESSION:,1. Hypertension controlled.,2. Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3. Urinary incontinence.,4. Recent sepsis.,PLAN:,1. I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2. I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3. See me back here in two months.,4. I made no changes in her medications.soap / chart / progress notes, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1319
}
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PREOPERATIVE DIAGNOSIS: ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1. Foreign body, left vallecula at the base of the tongue.,2. Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:, ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation. The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken. The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success. The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body. Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position. The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris. There was visualized some bilateral caudal spurring of the septum. The turbinates were within normal limits. There was some posterior nasoseptal deviation to the left. The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity. The nasal mucous membranes were pink and moist. There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally. There was evidence of some mild erythema in the right fossa Rosenmüller. There was no evidence of mass lesion or ulceration in this area, however. The eustachian tubes were patent without obstruction. The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized. There was evidence of a 1.5 cm left vallecular white foreign body. The rest of the oropharynx was without abnormality. The epiglottis was within normal limits and was noted to be omega in shape. There was no edema or erythema to the epiglottis. The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords. There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords. The laryngeal surface of the epiglottis was within normal limits. There was no evidence of mass lesion or nodularity of the vocal cords. The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion. The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam. The glottic aperture was completely patent with inspiration. The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits. The scope was then removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1. A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region. There is no evidence of supraglottic or piriform sinuses foreign body.,2. Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller. No mass is appreciated at this time.,PLAN:, The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m. Airway precautions were instituted. The patient currently remained in stable condition.ent - otolaryngology, oropharyngeal foreign body, flexible nasal laryngoscopy, nasal spray, foreign body, tongue, laryngoscopy, erythema, epiglottis, nasal, oropharyngeal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1320
}
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HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered.orthopedic, x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1321
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis. Biopsies were done. The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender. Lungs clear. Blood pressure 129/69 on admission. At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3. Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema. This was done and did not really show what the cecum on the barium enema. There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon. She did have some enemas. She had persistent nausea, headache, neck pain throughout this hospitalization. Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS: ,Migraine headache.,COMPLICATIONS: ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications. Diet and activity as tolerated.discharge summary, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1322
}
|
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, right eye.,PROCEDURE PERFORMED: ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling. The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops. Topical 4% lidocaine drops were used. The patient was prepped and draped in the normal sterile fashion. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters. This was exchanged for Viscoat solution. Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus. This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade. Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps. Balanced salt solution was used to hydrodissect the nucleus. Nuclear material was removed via phacoemulsification with divide-and-conquer technique. The residual cortex was removed via irrigation and aspiration. The capsular bag was then filled with Provisc solution. The wound was slightly enlarged. The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye. The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact. The lens was well centered in the capsular bag. The anterior chamber was deep. The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly. Maxitrol ointment was placed into the eye. The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.surgery, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1323
}
|
PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1. Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2. TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area.,ANESTHESIA,General endotracheal.,EBL,100 cc.,IV FLUIDS,2L.,URINE OUTPUT,Per Anesthesia.,INDICATION FOR SURGERY,The patient is a 48-year-old female who was seen in clinic by Dr. W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity. She requested that surgical procedures to be performed for correction of these abnormalities. As such, complications were explained to the patient including infection, bleeding, poor wound healing, and need for additional surgery. The patient subsequently signed the consent and requested that Dr. W and associates to perform the procedure.,TECHNIQUE,The patient was brought to the operating room in supine position. General anesthesia was induced and then the patient was placed on the operating table in a prone position. The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion. First, multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed. Once these varicose veins had been completely stripped and avulsed, then next the wounds were then irrigated and were cleaned with wet and dry, and all the incisions were closed with the use of 5-0 Monocryl buried interrupted sutures. The incisions were then dressed with Mastisol, Steri-Strips, ABDs and a TED hose. Next, the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position. The anterior chest was then prepped and draped in a sterile fashion. Next, a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty. Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts. Once the pectoralis muscle and fascia were identified, then a surgical plane was created in a subglandular layer. The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well. A sizer was used to identify the appropriate size of the silicone implant to be used. This was determined to be approximately 435 cc bilaterally. As such, two mammary gel silicone breast implants were placed in a subglandular muscle. Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants. Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant, the circumareolar incisions were closed in approximately 4-layered fashion closing the fascia, subcutaneous tissue, deep dermis, and a running dermal subcuticular for final skin closure. This was performed with 3-0 Monocryl and then 4-0 Monocryl for running subcuticular. The incisions were then dressed with Mastisol, Steri-Strips, and Xeroform and dressed with sample Kerlix. Next, our attention was paid to the face where 25% TCA solution was applied to two locations; one on the left cheek and the other one on the right cheek, where a hyperpigmentation/melasma. Several applications of the TCA peel was performed, and at the end of this, the frosting was noted to both spots. At the end of the case, needle and instrument counts were correct. Dr. W was present and scrubbed for the entire procedure. The patient was extubated in the operating room and taken to the PACU in stable condition.cosmetic / plastic surgery, breast hypoplasia, monocryl, pacu, tca, tca peel, ted hose, augmentation mammoplasty, breast implant, melasma, poor wound healing, popliteal fossa area, prepped and draped, silicone, varicose vein, vein stripping, mastisol steri strips, steri strips, circumareolar incisions, mammary gel, varicose veins, augmentation, breast, circumareolar, incisions, mammoplasty, mastisol, strips
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1324
}
|
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 weeks.,2. History of previous cesarean section x2. The patient desires a repeat section.,3. Chronic hypertension.,4. Undesired future fertility. The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 weeks.,2. History of previous cesarean section x2. The patient desires a repeat section.,3. Chronic hypertension.,4. Undesired future fertility. The patient desires permanent sterilization.,PROCEDURE PERFORMED: ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:, 800 mL.,COMPLICATIONS: ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term. The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization. The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie. The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted. The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. The placenta was delivered spontaneously 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. Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology. Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected. Hemostasis was visualized bilaterally. The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic. The uterine incision was reexamined and it was noted to be hemostatic. The pelvis was copiously irrigated. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.obstetrics / gynecology, bilateral tubal ligation, permanent sterilization, undesired future fertility, repeat cesarean section, intrauterine pregnancy, mayo scissors, kocher clamps, metzenbaum scissors, fallopian tube, babcock clamp, pomeroy method, rectus muscles, cesarean section, intrauterine, cesarean,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1325
}
|
CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:, This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back. He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling. He is now sleeping in an upright position. He was sent for CAT scan originally of his chest. The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion. He was subsequently was sent for a dedicated abdominal CAT scan and MRI. The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma. The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. Neoplasm could not be excluded. He was referred to us for further assessment. He denies any significant abdominal pain, any nausea or vomiting. His appetite is fine. He has had no significant changes in his bowel habits or any rectal bleeding or melena. He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps. He does have a history of frequent urination. Has been followed by urologist for this. There is no family history of pancreatic cancer. There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:, Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:, Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:, He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister.,SOCIAL HISTORY:, He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL: Presents as an obese 60-year-old white male, who appears to be in no apparent distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur.,HEART: There is distant heart sounds.,ABDOMEN: Obese. It is soft. It is nontender. Examination was done as relatively sitting up as the patient was unable to recline. Bowel sounds are present. There is no obvious mass or organomegaly.,GENITALIA: Deferred.,RECTAL: Deferred.,EXTREMITIES: Revealed about 1+ pitting edema. Bilateral peripheral pulses are intact.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION:, Both left adrenal and pancreatic lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy. We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention. Prior to that the patient will undergo an esophagogastroduodenoscopy.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1326
}
|
VITAL SIGNS:, Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:, Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. No papilledema, glaucoma, or cataracts. Ears: Normal set and shape with normal hearing and normal TMs. Nose and Sinus: Unremarkable. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy. Trachea is midline without stridor, shift, or subcutaneous emphysema. Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI is nondisplaced. Chest wall is unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:, No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age. Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:, Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness. No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable.,SKIN: ,Unremarkable for any premalignant or malignant condition with normal changes for age.general medicine, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1327
}
|
PREOPERATIVE DIAGNOSIS AND INDICATIONS:, Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:, The patient presented with an acute non-ST-elevation MI. Despite medical therapy, she continued to have intermittent angina. Angiography demonstrated the severe LAD as the culprit lesion. This was treated as noted above with angioplasty alone as the stent could not be safely advanced. She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above. She will be continued on her medical therapy. At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position. The area of the right femoral artery was prepped and draped in a sterile fashion. Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance. With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system. The catheter was removed. The sheath flushed. The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery. The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI. The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower. We repeated the level and it was slightly higher. We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV. Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal. An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated. Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent. The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium. The balloon was inflated and removed, repeat angiography performed. We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification. The stent was removed. Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful. It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed. Repeat angiography demonstrated no evidence of dissection. One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal. I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed. The guidewires and guide cath were removed. The sheath flushed and sutured into position. The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:, Aorta 185/54.,Left ventriculography was not performed. I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels. The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal. The LAD has significant calcification proximally. There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent. This resulted in a 30% residual, mostly eccentric calcified plaque. Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal. This was not ballooned. Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal. These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal. As noted above, this area was not stented because I could not safely advance the stent. Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches. The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal. The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch. The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch. The remainder of the right coronary and its branches were without significant disease.surgery, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1328
}
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PREOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,OPERATION:, Primary low-transverse C-section.,ANESTHESIA:, Epidural.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner. Anesthesia was tested and found to be adequate. Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally. Bleeders were bovied. Rectus muscles were separated from the overlying fascia with blunt and sharp dissection. Muscles were separated in the midline. Peritoneum was entered sharply and incision was carried out laterally in each direction. Bladder blade was placed and bladder flap developed with blunt and sharp dissection. A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction. Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance. Infant was carefully suctioned after delivery of the head and body. Cord blood was collected. _______ and endometrial cavity was wiped free of membranes and clots. Lower segment incision was inspected. There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic. Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present. Cul-de-sac was suctioned free of blood and clots and irrigated. Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated. Lower segment incision was again inspected and found to be hemostatic. The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin. Hemostasis was present between all layers. The area was gently irrigated across the peritoneum and fascial layers. There were no intraoperative complications except blood loss. The patient was taken to the recovery room in satisfactory condition.obstetrics / gynecology, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1329
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PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux. The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration. He has failed outpatient antibiotic therapy and conservative methods. At this time, he desires to attempt surgical correction. The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone. He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively. The wound was on the planar medial, distal and dorsal medial. The wound's bases were fibrous. They did not break the bone at this point. They were each approximately 0.5 cm in diameter. After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied. Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block. Next, the foot was prepped and draped in the usual aseptic fashion. It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected. Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium. Next, the incision was deepened through the subcutaneous tissue. A heavy amount of bleeding was encountered. Therefore, a Penrose drain was applied at the tourniquet, which failed. Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis. Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery. Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon. The long extensor tendon was thickened and overall exhibited signs of hypertrophy. The transverse incision through the long extensor tendon was made with a #15 blade. Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint. Next, the extensor tendon was peeled dorsally and distally off the bone. Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx. This bone was removed with a sharp dissection. Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx. This was passed off as the infected bone specimen for microbiology and pathology. Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx. Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins. The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline. Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin. This bone was found to be hard and healthy appearing. The wound after irrigation was free of all debris and infected tissue. Therefore anaerobic and aerobic cultures were taken and sent to microbiology. Next, OsteoSet beads, tobramycin-impregnated, were placed. Six beads were placed in the wound. Next, the extensor tendon was re-approximated with #3-0 Vicryl. The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits. A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap. The patient tolerated the above anesthesia and procedure without complications. He was transported via a cart to the Postanesthesia Care Unit. His vitals signs were stable and vascular status was intact. He was given a medium postop shoe that was well-formed and fitting. He is to elevate his foot, but not apply ice. He is to follow up with Dr. X. He was given emergency contact numbers. He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home. The patient was discharged in stable condition.orthopedic, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1330
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PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT: ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection. The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment. The patient now has exposed bone and osteomyelitis in the second toe. The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position. A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia. After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit. The foot and ankle were then prepped in the normal sterile orthopedic manner. The foot was elevated and an Esmarch bandage applied to exsanguinate the foot. The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table. Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site. Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit. Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint. Care was taken to identify bleeders and cautery was used as necessary for hemostasis. After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint. The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination. Attention was then directed to closure of the wound. All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident. Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges. Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety. Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin. Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin. This was obtained using #2-0 nylon suture. Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze. The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression. The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved. The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated. The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure. Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot. The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour. The patient was instructed to continue her regular medications. The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30. The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present. The second digit was sent to Pathology for gross and micro.podiatry, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1331
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DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1332
}
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PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:, Revision rhinoplasty (CPT 30450). Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture. During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma. The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect. The patient was consented for the above-stated procedure. The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues. In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear. Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb. Betadine was utilized for preparation. A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane. I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested. These were placed aside in saline. Hemostasis was obtained with bipolar electrocauterization. Bovie electrocauterization was also employed as needed. The entire length of the wound was then closed with 5-0 plain running locking suture. The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture. Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose. A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision. The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums. Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum. At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip. The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect. Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome. These were done transmucosally after elevating the tract using a Cottle elevator. Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms. The patient had a series of double-dome sutures placed into the nasal tip. Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing. Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation. A Gore-Tex small implant had been selected, previously incised. This was taken to the back table and carved under sterile conditions. The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum. It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut. The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage. This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis. The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures. The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic. There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum. The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition. He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area. He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.ent - otolaryngology, nasal deformity, rhinoplasty, conchal cartilage harvest, conchal bulb, conchal, submucoperichondrial, gull-wing incision, gore-tex, gull wing incision, lower lateral cartilages, revision rhinoplasty, nasal dorsum, cartilage harvest, conchal cartilage, cartilage, nasal, deformity, hemostasis, columella, harvest, cartilages
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1333
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FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery. It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit. The maternal tachycardia resolved within a day. The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%. It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state. An alert and oriented patient who is desirous at discharge. Full range of motion, all extremities; fully ambulatory. Pulse is regular and strong. Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. The incision is beautiful and soft and nontender. There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet. Follow up with me in 1 to 2 weeks. Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.consult - history and phy., delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1334
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HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare. This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon. Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy. On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon. He has been followed conservatively since that time. A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg. Right coronary artery to pulmonary artery fistula was also appreciated. The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:, The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case. 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 7-French sheath, a 6-French wedge catheter was inserted. The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries. This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,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 was normal with no evidence of intracardiac shunt. Left-sided heart was fully saturated. Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Right ventricular systolic pressure was mildly elevated at 45% systemic level. There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries. Phasic branch pulmonary artery pressures were normal. Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency. The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation. There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus. The pulmonary valve appeared to be thin and moved well. The median branch pulmonary arteries were of good size with normal distal arborization. Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1. Membranous pulmonary atresia.,2. Atrial septal defect.,3. Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS): ,1. Pulmonary valvotomy surgical.,2. Aortopulmonary artery central shunt.,3. Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES: ,1. Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2. Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3. Small right coronary artery to main pulmonary fistula.,4. Static encephalopathy.,5. Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference. Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated. Conservative outpatient management is to be recommended. Further patient care will be directed by Dr. X.surgery, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1335
}
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PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1. Atrophic dry cracked nasal mucosa.,2. Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess. The patient was taken to the operating room for incision and drainage. Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis. Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery. The patient does report of having endotracheal tube intubation during anesthesia. The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:, After the procedure was described, the patient was placed in the seated position. The fiberoptic nasal laryngoscope was then inserted into the patient's left naris. The nasal mucosal membranes were dry and atrophic throughout. There was no evidence of any mass lesions. The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity. There was no evidence of mass, ulceration, lesion, or obstruction. The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes. There was no evidence of any local mass lesion, nodule, or ulcerations. There was no evidence of any erythema. Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric. The airway was stable and patent throughout the entire examination. The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx. The eustachian tube was completely visualized and was patent without obstruction. The scope was then further removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris. At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma. If this becomes possible in the future, this may provide her some relief of her chronic dysphonia. The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.surgery, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1336
}
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PREOPERATIVE DIAGNOSIS:, Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled. He has had multiple severe carious lesions that warrant multiple extractions at this time. It is also unclear to me as to how his prior or existing restorations were accomplished. In any case, he has been cleared for the procedure today. He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position. Dr. X administered the general anesthetic, after which a throat pack was placed. Available full mouth x-rays were reviewed. These x-rays were taken at another location. Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies. All of these aforementioned teeth were extracted using combinations of forceps and elevators. Hemostasis in all of these sites was accomplished with direct pressure using gauze packs. ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal. These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces. ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite. ,Tooth 7 had caries involving the distal surface. ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area. These carious lesions were excavated, and both of these teeth were restored with composite. ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite. ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam. ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly. The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours. There was negligible blood loss.surgery, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1337
}
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CHIEF COMPLAINT:, Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively. She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services. Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0. She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery. Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY:, Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS: ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:, As mentioned above. She has a history of migraine headaches associated with her menstrual cycle. She wears glasses and has a history of floaters. She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign. The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis. She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery. She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties. First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL: No acute distress at the time of exam.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Dentition is in good repair.,NECK: Trachea is at the midline.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm.,ABDOMEN: Bowel sounds are heard throughout. Soft and nontender.,EXTREMITIES: Right hip incision is clean, intact, and no drainage is noted. There is diffuse edema, which extends distally. There is no calf tenderness per se bilaterally and Homans sign is negative. There is no pedal edema.,MENTAL STATUS: Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6. The BUN was normal at 8, creatinine was 0.9, INR was 1.49. CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1. Status post right total hip replacement. The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2. Postoperative anemia, Feosol 325 mg one q.d.,3. Pain management. Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain. Additionally, she will utilize ice to help decrease edema.,4. Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5. Osteoarthritis, Celebrex 200 mg b.i.d.,6. GI prophylaxis, Protonix 40 mg b.i.d. Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7. DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR. She will continue on 5 mg every day.,8. Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis. Monitor for any possibility of DVT.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1338
}
|
EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:, A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy. Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes. There are subtle areas of increased attenuation seen within the frontal lobes bilaterally. Given the patient's clinical presentation, these likely represent small hemorrhagic contusions. Other differential considerations include cortical calcifications, which are less likely. The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation. The orbits and extra-ocular muscles are within normal limits. There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses. The remaining visualized paranasal sinuses and mastoid air cells are clear. Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia. There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation. The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis. The central canal is grossly patent. The pedicles and posterior elements appear intact with multifocal facet degenerative changes. There is no prevertebral or paravertebral soft tissue masses identified. The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions. There is no associated shift or mass effect at this time. Less likely, this finding could be secondary to cortical calcifications. The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1339
}
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DELIVERY NOTE: ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor. The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum. Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes. No meconium was noted. Infant was delivered on 12/25/08 at 2154 hours. Two doses of ampicillin was given prior to rupture of membranes. GBS status unknown. Intrapartum events, no prenatal care. The patient had epidural for anesthesia. No observed abnormalities were noted on initial newborn exam. Apgar scores were 9 and 9 at one and five minutes respectively. There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child. Placenta was delivered spontaneously and was normal and intact. There was a three-vessel cord. Baby was bulb suctioned and then sent to newborn nursery. Mother and baby were in stable condition. EBL was approximately 500 mL, NSVD with postpartum hemorrhage. No active bleeding was noted upon deliverance of the placenta. Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone. Pitocin was started following deliverance of the placenta. Baby delivered vertex from OA position. Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.surgery, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1340
}
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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.surgery, 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_4",
"dataset_name": "medical-transcription-4",
"id": 1341
}
|
CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on the papoose board. The external genitalia were prepped with Betadine. A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis. The incision was made. Next, all the adhesions of the inner preputial skin were broken down. The appropriate size bell was obtained and placed over the glans penis. The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco. The bell was then placed and tightened down. Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum. A blade was used to incise circumferentially around the bell. The bell was removed. There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed. The little boy was given back to his mom.,PLAN:, They have a new baby checkup in the near future with their primary care physician. I will see them back on a p.r.n. basis if there are any problems with the circumcision.surgery, neonatal, circumcision, gomco, gomco clamp, external genitalia, foreskin, glans, glans penis, infant, meatal stenosis, penile block, penis, preputial skin, circumferentially, infection, bell,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1342
}
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PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed. The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD. The patient is fed by mouth and also with nasogastric enteral feeding supplements. She has had an __________ cough and relatively disinterested in oral intake for the past month. She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted. Based on the history, it is quite possible this coin has been there close to a month. She is brought to the operating room now for attempted removal. I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time. Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location. There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive. The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia. She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications. After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism. A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view. This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen. At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps. I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved. The patient tolerated the procedure well. There were no intraoperative complications. There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.surgery, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1343
}
|
PREOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,OPERATION:, Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,ANESTHESIA: ,General.,INDICATIONS:, This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate. He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA: ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria. He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1. Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia. Prepped and draped in the dorsal lithotomy position. A 27-French Olympus rectoscope was passed via the urethra into the bladder. The bladder, prostate, and urethra were inspected. He had an obstructing prostate. He had marked catheter reaction in his bladder. He had a lot of villous changes, impossible to tell from frank tumor. He had a huge bladder calculus. It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone. There was still stone left at the end of the procedure. Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB. We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP. We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.surgery, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1344
}
|
A 1 cm infraumbilical skin incision was made. Through this a Veress needle was inserted into the abdominal cavity. The abdomen was filled with approximately 2 liters of CO2 gas. The Veress needle was withdrawn. A trocar sleeve was placed through the incision into the abdominal cavity. The trocar was withdrawn and replaced with the laparoscope. A 1 cm suprapubic skin incision was made. Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope. The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis. Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal. The probe was withdrawn and replaced with the bipolar cautery instrument. The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus. Electrical current was applied to the tube at this point and fulgurated. The tube was then regrasped just distal to this and refulgurated. It was then regrasped just distal to the lateral point and refulgurated again. The same procedure was then carried out on the opposite tube. The bipolar cautery instrument was withdrawn and replaced with the probe. The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes. The upper abdomen was visualized, and the liver surface was normal. The gas was allowed to escape from the abdomen, and the instruments were removed. The skin incisions were repaired. The instruments were removed from the vagina.,There were no complications to the procedure. Blood loss was minimal. The patient went to the postanesthesia recovery room in stable condition.obstetrics / gynecology, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1345
}
|
PREOPERATIVE DIAGNOSIS:, Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE: ,Vitrectomy, right eye.,PROCEDURE IN DETAIL: ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus. MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture. Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed. All strands of significance were removed. Tractional detachment foci were apparent posteriorly along the temporal arcades. Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control. Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control. The intraocular pressure was within the normal range. The globe was irrigated with a topical antibiotic. The MVR incisions were closed with 7-0 Vicryl. No further manipulations were necessary. The conjunctiva was closed with 6-0 plain catgut. An eye patch was applied and the patient was sent to the recovery area in good condition.ophthalmology, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1346
}
|
PREOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic. He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus. The left shoulder and upper extremities were then prepped and draped in the usual manner. A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus. This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery. Hemostasis was achieved with the cautery. The deltoid fascia were identified, skin flaps were then created. The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein. The deltoid was then retracted. There was marked hematoma and swelling within the subdeltoid bursa. This area was removed with rongeurs. The biceps tendon was identified which was the landmark for the rotator interval. Mayo scissors was utilized to split the remaining portion of the rotator interval. The greater tuberosity portion with the rotator cuff was identified. Excess bone was removed from the greater tuberosity side to allow for closure later. The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well. Both of these were tagged with Ethibond sutures for later. The humeral head was delivered out of the wound. It was localized to the area of the anteroinferior glenoid region. The glenoid was then inspected, and noted to be intact. The fracture was at the level of the surgical neck on the proximal humerus. The canal was repaired with the broaches. An #8 stem was chosen as it was going to be cemented into place. The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion. Trial reduction was performed. The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder. At this point, the wound was copiously irrigated with gentamycin solution. The canal was copiously irrigated as well and suctioned dry. Methyl methacrylate cement was mixed. The cement gun was filled and the canal was filled with the cement. The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured. Excess cement was removed by sharp dissection. Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later. Once the cement was cured, the modular head was impacted on to the Morse taper. It was stable and the shoulder was reduced. The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant. The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well. The rotator interval was closed with #2 fiber wire in an interrupted fashion. The biceps tendon was ________ within this closure. The wound was copiously irrigated with gentamycin solution, suctioned dry. The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture. Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples. Subcutaneous tissues were infiltrated with 0.25% Marcaine solution. A bulky dressing was applied to the wound followed by application of a large arm sling. Circulatory status was intact in the extremity at the completion of the case. The patient was then transferred to recovery room in apparent satisfactory condition.orthopedic, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1347
}
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PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1. Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2. Microdissection.,3. NIM facial nerve monitoring for three hours.,COMPLICATIONS: ,None.,FINDINGS:, There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall. There was a significant amount of myringosclerosis and tympanosclerosis. There is some mild erosion of the lenticular process of the incus. The facial nerve was normal. We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty. The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure. There was no abnormal activity during this case. We inspected the ear canal, identified the huge defect, which was completely filled with cerumen. Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion. We reopened the previously used postauricular incision and dissected down the mastoid cortex. We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone. A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out. We went all the way to the mastoid antrum. We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus. We removed the lateral aspect of the mastoid tip. We lowered the facial ridge. The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus. We separated the incus from the stapes and then removed it. We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation. The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed. There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move. We carefully dissected this out. This did seem to improve the mobility of the stapes somewhat. At this point, there was a near total perforation. There was only a minimal amount of anterior remnant of the drum left. We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place. He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage. We harvested a few pieces as best as we could. We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions. We excised cartilage posteriorly and inferiorly to enlarge the meatus. This cartilage was thin and used for cartilage tympanoplasty. We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it. We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap. A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants. We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear. Glasscock dressing was applied. The patient was awakened from anesthesia and taken to the recovery room in stable condition. He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.ent - otolaryngology, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1348
}
|
ABNORMAL CHOLESTEROL RESULT LETTER,Recently you had a cholesterol test done. The cholesterol levels were abnormal. These are usually associated with increased risk for stroke and heart attack. I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best step. I would like you to make an appointment, if you are interested in treatment for this. There are several treatment options available at this time. Diet is one of the options, although there is limited reduction in total cholesterol and LDL cholesterol with dieting. Most of the time under strict diet patients can achieve a 15% reduction in cholesterol. If your cholesterol levels are moderate to severely elevated, usually diet is not the first line of therapy. If you are diabetic or have hypertension these two also increase your risk with the combination of hypercholesterolemia. Most of the time cholesterol that is elevated is from your genetic background and is independent of diet. New research shows that treatment of high cholesterol can decrease your risk of developing Alzheimer’s disease.,Again, I am recommending at least we discuss medical treatment for hypercholesterolemia. Please consider calling for a followup appointment concerning your cholesterol levels. If you should have any further questions, please do not hesitate to contact me. I am enclosing a copy of your lab results for your review.letters, letter, ldl, abnormal, cholesterol, cholesterol level, cholesterol test, heart attack, hypercholesterolemia, increased risk, lab results, stroke, total cholesterol, abnormal cholesterol result, abnormal cholesterol, cholesterol levels, levels, treatment, dietNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1349
}
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PRINCIPAL DIAGNOSES:,1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4. Diabetes.,5. Bipolar disorder.,6. Chronic muscle aches.,7. Chronic lower extremity edema.,8. ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1. Paxil 40 mg once daily.,2. Cozaar.,3. Xanax 1 mg four times a day.,4. Prozac 20 mg a day.,5. Lasix 40 mg a day.,6. Potassium 10 mEq a day.,7. Mirapex two tablets every night.,8. Allegra 60 mg twice a day.,9. Avandamet 4/1000 mg daily.,10. Nexium 20 mg a day.,11. NovoLog 25/50.,REVIEW OF SYSTEMS:, Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact.,LABORATORY DATA:, White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.,3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.,4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5. He is followed for his diabetes by his internist.,6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1350
}
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PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:, 400 ml.,SPECIMENS REMOVED:, Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1. Type 2 aortic arch.,2. Left subclavian artery was patent.,3 Left vertebral artery was patent.,4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:, Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.cardiovascular / pulmonary, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1351
}
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ADMISSION DIAGNOSIS:, Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:, Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:, Stable.,PROCEDURES PERFORMED:, Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE: ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. The patient recovered well after this. Working with PT, she was able to ambulate with minimal assistance. Nerve block was removed by anesthesia. The patient did well on oral pain medications. The patient was discharged home. She is actually going to home with her son who will be able to assist her and look after her for anything she might need. The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks.orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1352
}
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PREOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,POSTOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,NAME OF OPERATION: , Excision of bilateral chronic hydradenitis.,ANESTHESIA:, Local.,FINDINGS: , This patient had previously had excision of hydradenitis. However, she had residual disease in both axilla with chronic redraining of the cyst from hydradenitis. This now is controlled and it was found to be suitable for excision. There was an area in each axilla which needed to be excised.,PROCEDURE: , Under local infiltration and after routine prepping and draping, an elliptical incision was first made on the left side to encompass the area of chronic hydradenitis. This wound was then irrigated with saline. The deeper layers were closed using interrupted 3-0 Vicryl. The skin was closed using interrupted 5-0 nylon.,Attention was then directed to the right side where a similar procedure was carried out encompassing the involved area with the closure being identical to the opposite side. This appeared to encompass all of the active area of hydradenitis.,The needle counts were all correct. No intraoperative complications were encountered. Dressings were applied, and the patient was returned to the recovery room in satisfactory condition.surgery, hydradenitis, elliptical incision, bilateral hydradenitis, chronic hydradenitis, axilla, excision, chronic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1353
}
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PREOPERATIVE DIAGNOSIS:, Right breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:, Right breast mass with abnormal mammogram.,PROCEDURE PERFORMED:, Right breast excisional biopsy with needle-localization.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Right breast mass and confirmation by Radiology that the specimen was received with the mass was in the specimen.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,The patient is a 41-year-old female who presented to Dr. X's office with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,PROCEDURE: , After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite. After IV sedation was given, the patient was prepped and draped in normal sterile fashion. A radial incision was made in the right lateral breast with a #10 blade scalpel. The needle was brought into the field. An Allis was used to grasp the breast mass and breast tissue using the #10 scalpel. The mass was completely excised and sent out for specimen after confirmation by Radiology that the mass was in the specimen.,Hemostasis was then obtained with electrobovie cautery. The skin was then closed with #4-0 Monocryl in a running subcuticular fashion. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition.surgery, breast mass, mammogram, breast excisional biopsy, needle-localization, excisional biopsy, abnormal mammogram, breast, radiology, scalpel, excisional, biopsy, needle, specimen, mass
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1354
}
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GROSS DESCRIPTION: , Specimen labeled "right ovarian cyst" is received fresh for frozen section. It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid. Both surfaces of the wall are pink-tan, smooth and grossly unremarkable. No firm or thick areas or papillary structures are noted on the cyst wall externally or internally. After removal the fluid, the cyst weight 68 grams. The fluid is transparent and slightly mucoid. A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,obstetrics / gynecology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1355
}
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REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade. She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam. She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better. She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity. Since around 6 to 7 years, she has had a head tremor, which is mainly "no- no" and occasional voice tremor also. Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart. She also has some stress incontinence. Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1. Klonopin 0.5 mg twice a day.,2. Primidone 100 mg b.i.d.,3. Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension. Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol. She is married since 44 years, has 3 children. She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting. No visual complaints. She complains of hearing decreased on the left. No chest pain or shortness of breath. No constipation. She does give a history of urge incontinence. No rashes. No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg. HEENT: PERRLA. EOMI. CARDIOVASCULAR: S1 and S2 normal. Regular rate and rhythm. She does have a rash over the right ankle with a prior basal cell carcinoma was resected. NEUROLOGIC: Alert and oriented x4. Speech shows a voice tremor occasionally. Language is intact. Cranial nerves II through XII intact. Motor examination showed 5/5 power in all extremities with minimal increased tone. Sensory examination was intact to light touch. Reflexes were brisk bilaterally, but they were equal and both toes were downgoing. Her coordination showed minimal intentional component to bilateral finger-to-nose. Gait was intact. Lot of swing on Romberg's. The patient did have a tremor both upper extremities, right more than left. She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. The patient did not wish to change any of her medication doses at this point. We will go ahead and check MRI brain, and we will get the films later. We will see her back in 3 months. Also, the patient declined any possible Botox for the mild torticollis she has at this point.neurology, clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1356
}
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GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers. No tattoos.,NECK:, Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:, Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.,LUNGS:, Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.,MUSCULOSKELETAL:, Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.,GENITOURINARY: ,Deferred.,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1357
}
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EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia. The patient has diffuse abdominal pain. There is a history of AIDS.,TECHNIQUE:, An ultrasound examination of the abdomen was performed.,FINDINGS:, The liver has normal echogenicity. The liver is normal sized. The gallbladder has a normal appearance without gallstones or sludge. There is no gallbladder wall thickening or pericholecystic fluid. The common bile duct has a normal caliber at 4.6 mm. The pancreas is mostly obscured by gas. A small portion of the head of pancreas is visualized which has a normal appearance. The aorta has a normal caliber. The aorta is smooth walled. No abnormalities are seen of the inferior vena cava. The right kidney measures 10.8 cm in length and the left kidney 10.5 cm. No masses, cysts, calculi, or hydronephrosis is seen. There is normal renal cortical echogenicity. The spleen is somewhat prominent with a maximum diameter of 11.2 cm. There is no ascites. The urinary bladder is distended with urine and shows normal wall thickness without masses. The prostate is normal sized with normal echogenicity.,IMPRESSION: ,1. Spleen size at the upper limits of normal.,2. Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas. The visualized portion of the head had a normal appearance.,3. The gallbladder has a normal appearance without gallstones. There are no renal calculi.gastroenterology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1358
}
|
OPERATIONS/PROCEDURES,1. Insertion of right internal jugular Tessio catheter.,2. Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The right neck, chest and left arm were prepped and draped in a sterile fashion. A small incision was made at the top of the anterior jugular triangle in the right neck. Through this small incision, the right internal jugular vein was punctured and a guidewire was placed. It was punctured a 2nd time, and a 2nd guidewire was placed. The Tessio catheters were assembled. They were measured for length. Counter-incisions were made on the right chest. They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs. They were flushed with saline. A suture was placed through the guidewire, and the guidewire and dilator were removed. The arterial catheter was then placed through this, and the tear-away introducer was removed. The catheter aspirated and bled easily. It was flushed with saline and capped. This was repeated with the venous line. It also aspirated easily and was flushed with saline and capped. The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon. Dressings were applied. An incision was then made at the left wrist. The basilic vein was dissected free, as was the radial artery. Heparin was given, 50 mg. The radial artery was clamped proximally and distally with a bulldog. It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed. The vein was clipped distally, divided and spatulated for anastomosis. It was sutured to the radial artery with a running 7-0 Prolene suture. The clamps were removed. Good flow was noted through the artery. Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin. The patient tolerated the procedure well.cardiovascular / pulmonary, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1359
}
|
PROCEDURE:,: Informed consent was obtained from the patient. Special mention was made of the possibility of infection and necrosis of the heel pad. The patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle. The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus. The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly. The contents of the syringe were then gently injected. Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site. Subsequently the needle was removed. Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours.pain management, plantar fascia injection, plantar fascia, calcaneus, heel pad, necrosis, depo-medrol, bandage, medial aspect, heel, syringe, injection, needleNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1360
}
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REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above. Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:, Reviewed as above and otherwise unchanged.,FAMILY HISTORY:, Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS: ,1. Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2. G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3. Fluconazole 37.5 mg daily.,4. Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. Vital Signs: Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg. Eyes: Conjunctivae are clear, nonicteric. Pupils are equally round and reactive to light. Extraocular muscle movements appear intact with no strabismus. Ears: TMs are clear bilaterally. Oral Mucosa: No thrush is appreciated. No mucosal ulcerations or erythema. Chest: Port-a-Cath is nonerythematous and nontender to VP access port. Respiratory: Good aeration, clear to auscultation bilaterally. Cardiovascular: Regular rate, normal S1 and S2, no murmurs appreciated. Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. Skin: No rashes. Neurologic: The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974. Medical tests none. Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES: ,1. Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2. History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3. Immunosuppression.,4. Mucosal candidiasis.,5. Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:, None.,PLANS: ,1. Neuroblastoma. The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. I will plan for restaging with CT of the abdomen prior to the cycle.,2. Immunosuppression. The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday. Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3. Mucosal candidiasis. We will continue fluconazole for thrush. I am pleased that the clinical evidence of disease appears to have resolved. For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time. We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient. This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF. His ANC is nicely recovered. He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. He continues on fluconazole for recent history of thrush. Plans are otherwise documented above.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1361
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PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT: ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE: ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1362
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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.surgery, 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_4",
"dataset_name": "medical-transcription-4",
"id": 1363
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REASON FOR VISIT: , Ms. ABC is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation. She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS:, She has been followed for her hydrocephalus since 2002. She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007. She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0. We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine. Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes. She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes. She does experience some leakage with coughing. She wears the pad on a daily basis. She does not think that her bladder has changed much since we saw her last. With respect to her thinking and memory, she reports no problems at this time. She reports no headaches at this time. With respect to her walking and balance, she says that it feels worse. In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs. She states that her leg often feel like elastic and she experiences a tingling radiculopathy. She says that this tingling is constant and at times painful. She feels that she is walking slower for this reason. She does not use the cane at this time. Most of the time, she is able to walk over uneven surfaces. She is able to walk up and down stairs and has no trouble getting in and out of a car.,MEDICATIONS:, Rhinocort 32 mg two sprays a day, Singulair 10 mg once a day, Xyzal 5 mg in the morning, Spiriva once a day, Advair twice a day, Prevacid 30 mg twice a day, Os-Cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day.,MAJOR FINDINGS:, On exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty. She is well developed, well nourished, and kempt.,The shunt site is clean, dry, and intact and confirmed at a setting of 1.0.,Mental Status: Assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. Her Mini-Mental Status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling.,Cranial Nerves: Extraocular movements are somewhat inhibited. She does not display any nystagmus at this time. Facial movement, hearing, head turning, tongue, and palate movement are all intact.,Gait: Assessed using the Tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28.,ASSESSMENT:, Ms. ABC has been experiencing difficulty with walking over the past several months.,PROBLEMS/DIAGNOSES:,1. Hydrocephalus.,2. Cervical stenosis and retrolisthesis.,3. Neuropathy in the legs.,PLAN: , Before we recommend anything more, we would like to get a hold of the notes from Dr. XYZ to try to come up with a concrete plan as to what we can do next for Ms. ABC. We believe that her walking is most likely not being effected by the hydrocephalus. We would like to see her back in clinic in two and a half months or so. We also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one. I suggested that she use the cane at her on discretion.neurology, cervical stenosis, retrolisthesis, neuropathy, cervical corpectomy, adult hydrocephalus, cervical, hydrocephalus,
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{
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"dataset_name": "medical-transcription-4",
"id": 1364
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PREOPERATIVE DIAGNOSES,1. Bilateral bronchopneumonia.,2. Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1. Bilateral bronchopneumonia.,2. Empyema of the chest, left.,PROCEDURES,1. Diagnostic bronchoscopy.,2. Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRIPTION OF PROCEDURE:, After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed. Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy. Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.,Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope. Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems. Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.,Then, the patient was turned with left side up and prepped for a left thoracotomy. He was properly draped. I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space. Immediately, it was evident that there was a large amount of pus in the left chest. We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus. Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung. We spent several minutes trying to clean up this area. Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure. On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations. We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.,The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.,The chest tubes were secured with sutures and then connected to Pleur-evac. Then, the patient was transported.,Estimated blood loss was minimal and the patient tolerated the procedure well. He was extubated in the operating room and he was transferred to the ICU to be admitted. A chest x-ray was ordered stat.surgery, chest tubes, insertion, partial pulmonary decortication, thoracotomy, bronchoscopy, empyema, bronchopneumonia, diagnostic bronchoscopy, pulmonary decortication, bilateral bronchopneumonia, decortication, intercostal, pulmonary, tubes,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1365
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CLINICAL INDICATION:, Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm. The patient was stressed according to Bruce protocol by Dr. X. Exercise test was supervised and interpreted by Dr. X. Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact. There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2. Normal LV systolic function with LV ejection fraction of 59%.cardiovascular / pulmonary, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1366
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PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,surgery, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1367
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SUBJECTIVE:, The patient is a 75-year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert. She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck. She said she had an earache a day or so ago. She has not had any cold symptoms.,ALLERGIES:, Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:, The patient says that she feels little bit nauseated at times. She denies chest pain or shortness of breath and again feels like she has something in her throat. She has been able to swallow liquids okay. She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth. She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General: She is awake and alert, no acute distress.,Vital Signs: Blood pressure: 175/86. Temperature: She is afebrile. Pulse: 78. Respiratory rate: 20. O2 sat: 93% on room air.,HEENT: Her TMs are normal bilaterally. Posterior pharynx is unremarkable. It should be noted that her uvula did not deviate and neither did her tongue. When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck: Without adenopathy or thyromegaly. Carotids pulses are brisk without bruits.,Lungs: Clear to auscultation.,Heart: Regular rate and rhythm without murmur.,Extremities: Her muscle strength is symmetrical and intact bilaterally. DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities. She has a positive Tinel’s sign on her left wrist.,Neurological: I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:, Bell’s Palsy.,PLAN:, We did get an EKG showed some ST segment changes anterolaterally. The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG. I assured her that it does not look like she has a stroke. If she wants to prevent a stroke, obviously quitting her smoking would help. It should be noted she also takes Synthroid and Zocor. We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.soap / chart / progress notes, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1368
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CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:,chiropractic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1369
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PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:, Release of A1 pulley, right thumb.,ANESTHESIA:, IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY: ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb. She was actually able to spontaneously trigger the thumb. She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley. All risks and benefits of the surgery was discussed with her at length. She was in agreement with the above treatment plan.,PROCEDURE: ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table. A regional anesthetic was applied by the Anesthesia Department. Tourniquet was placed on her proximal arm. The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb. Subcuticular tissues were carefully dissected. Hemostasis was controlled with electrocautery. The nerves were identified and retracted throughout the entire procedure. The fibers of the A1 pulley were identified. They were sharply dissected to release the tendon. The tendon was then pulled up into the wound and inspected. There was no evidence of gross tear noted. Fibrous nodule was noted within the tendon itself. There was no evidence of continuous locking. Once release of the pulley had been performed, the wound was copiously irrigated. It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures. Sterile dressing was applied to the upper extremity. Tourniquet was deflated. It was noted that the thumb was warm and pink with good capillary refill. The patient was transferred to Recovery in apparent stable and satisfactory condition. Prognosis is fair.orthopedic, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1370
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DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. Cord clamped and cut and infant handed to the awaiting nurse in attendance. Cord blood sent for analysis, intact. Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours. A 15 units of Pitocin was started after delivery of the placenta. Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion. Estimated blood loss was approximately 400 mL. The patient was taken to the recovery room in stable condition. Infant was taken to Newborn Nursery in stable condition. The patient tolerated the procedure well. The only intrapartum event that occurred was thick meconium. Otherwise, there were no other complications. The patient tolerated the procedure well.surgery, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1371
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The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS: Proximal and mid esophagus were without abnormalities.,STOMACH: Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM: Normal.gastroenterology, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1372
}
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IDENTIFYING DATA:, Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior. Recently, she was picked up by Kent Police Department "leaping on Highway 99.",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY: ,Unknown.,ALLERGIES:, Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:, Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit. General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2. Previous urine tox was positive for THC. Urinalysis was negative, but did note positive UA wbc's. CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I: Psychosis. Inpatient Psychiatric Team to follow.,AXIS II: Deferred.,AXIS III: We were unable to perform physical examination on the patient today secondary to her being in seclusion. Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI. We will wait until the patient is out of seclusion to perform examination. Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy. We will followup with the patient should any new medical issues arise.psychiatry / psychology, ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1373
}
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REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well. He has a relatively unremarkable foreskin. At this point in time, he otherwise seems to be doing reasonably well. The question is about the foreskin. He otherwise has no other significant issues. Severity low, ongoing since birth two weeks. Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:, Male exam. Normal and under the penis, report normal uncircumcised 2-week-old. He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe. I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision. This kid should otherwise do reasonably well.,PLAN: ,Follow up as needed. But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1374
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CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY: ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES: Grossly and neurovascularly intact.,LABORATORY VALUES: ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:, EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1375
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|
REASON FOR CONSULTATION:, Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1. Graves disease.,2. Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3. Diverticulosis.,4. GERD.,5. High blood pressure.,6. Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT: ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today. Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking. On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No recent fever or general malaise.,ENT: Unremarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: No chest pain.,GASTROINTESTINAL: No nausea or vomiting.,GENITOURINARY: The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE: Negative for diabetes, but positive for Graves disease.,MEDICATIONS: ,The patient takes Synthroid and aspirin. Aspirin had been discontinued about 1 week ago. He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL: A 71-year-old gentleman, not in acute distress.,CHEST: Clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: There is no swelling.,NEUROLOGICAL: The patient is alert and oriented x3. Examination is nonfocal.,ASSESSMENT AND PLAN:,1. Perioperative hypertension. We will restart lisinopril at half the previous dose. He will be on 20 mg p.o. daily. If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily. The patient should see his primary physician, Dr. Y in 2 weeks' time. If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2. Prostatic hypertrophy, status post laser surgery. The patient tolerated the procedure well.,3. History of Graves disease.,4. History of atrial fibrillation. The patient is in normal sinus rhythm.,DISPOSITION: ,The patient is stable to be discharged to home. Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1376
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LONG-TERM GOALS:, Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community. This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home. During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill. She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued. The patient and her husband both agreed with the patient's discharge.discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1377
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CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she "was drunk." Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:, ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid.neurology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1378
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PREOPERATIVE DIAGNOSES: , Bladder laceration.,POSTOPERATIVE DIAGNOSES:, Bladder laceration.,NAME OF OPERATION: , Closure of bladder laceration.,FINDINGS:, The patient was undergoing a cesarean section for twins. During the course of the procedure, a bladder laceration was notices and urology was consulted. Findings were a laceration on the dome of the bladder.,PROCEDURE: , Initially there as a mucosal layer of suture already placed. This was done with 3-0 chromic catgut. The bladder was distended and, while the bladder was distended with physiologic saline, a second layer of 3-0 chromic catgut created a watertight closure. The second layer included the mucosa an dinner layer of the detrusor muscle. A third layer of 2-0 Dexon was used. Each of these were placed in a continuous running-locked suture technique. There was complete watertight closure of the bladder. Hemostasis was assured and a Jackson-Pratt drain was brought out through a separate stab wound. The remaining portion of the operation, both the cesarean section and the wound closure, will be dictated by Dr. Redmond.surgery, mucosal layer, closure of bladder laceration, watertight closure, cesarean section, bladder laceration, bladder, cesarean, closure, laceration,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1379
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ALLOWED CONDITIONS:, Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:, Osteoarthritis of the left knee.,EMPLOYER:, ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee. He is a 57-year-old assembly worker who was injured on June 13, 2007, which according to his FROI was due to "repairing cars, down on knees to work on concrete floors." In addition, he slipped on an air hose on the floor at work on March 7, 2007, re-injuring his left knee. He developed pain and swelling in his left knee. He denies having any difficulties with his left knee prior to the injury of June 13, 2002.,DIAGNOSTIC STUDIES: , August 2, 2002, MRI of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade II to III chondromalacia of the medial joint space. On June 26, 2007, MRI of his left knee was referred to in the injury management report of June 19, 2007, as showing osteoarthritis of the medial compartment has advanced. He brought with him copies of x-rays taken July 16, 2007, of his left knee, which I reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella. There was subluxation of the tibia on the femur with standing.,After his injury, he received treatment from Dr. X for patellofemoral syndrome with knee sleeve. He also received treatment from Dr. Y also for left knee sprain and patellar pain. He also did exercise, does use a knee sleeve and Aleve. On December 5, 2002, he underwent arthroscopy of the left knee by Dr. Z who did a partial resection of a torn medial meniscus. He also noticed grade III chondromalacia of the patella as well as the torn medial meniscus. He states that he was asymptomatic until he slipped on an air hose while at work on March 7, 2007, and again developed pain and swelling in his left knee. Standing aggravates his pain. He has had one injection of cortisone by Dr. Z about a month ago, which has helped his pain. He takes one hydrocodone 7.5/750 mg daily.,Examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf. There was patellar crepitus with knee motion. There was no motor weakness or reflex changes. He walked without a limp and could stand on his heels and toes equally well. There was no instability of the knee and no effusion. Range of motion was 0 to 120 degrees.,QUESTION: , Xxxxx has recently filed to reactivate this claim. Please give me your opinion as to whether Xxxxx's current clinical presentation is related to the industrial injury stated above.,ANSWER:, Yes. His original MRI of August 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade II to III chondromalacia of the medial joint space, which was the beginning of osteoarthritis. Also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of June 13, 2007, specifically to the torn medial meniscus.,QUESTION: ,Do I believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,ANSWER:, Yes, I believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,QUESTION:, Xxxxx has filed an application for additional allowance of osteoarthritis of the left knee. Based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER: ,Yes. Please see the discussion in the answer to question no one. In addition, x-rays of July 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,QUESTION: , If you find this condition exists, is it a direct and proximate result of the June 13, 2002, injury?,ANSWER:, Yes. See discussion in answer to question number one.,QUESTION: , Do you find that Xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,ANSWER: ,No. I believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,QUESTION: , In addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to Xxxxx's condition?,ANSWER:, No. He does not give any history of any intervening injuries.,If you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,QUESTION:, Based on the objective findings is the request for 10 sessions of physical therapy per C-9 dated July 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,ANSWER:, Yes.,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1380
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SUBJECTIVE:, This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently.,CURRENT MEDICATIONS:, Advair and Allegra. He has been taking these regularly. He is not sure the Allegra is working for him anymore. He does think though better than Claritin.,PHYSICAL EXAM:,General: Alert young man in no distress.,HEENT: TMs clear and mobile. Pharynx clear. Mouth moist. Nasal mucosa pale with clear discharge.,Neck: Supple without adenopathy.,Heart: Regular rate and rhythm without murmur.,Lungs: Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen: Soft, nontender, without masses or splenomegaly.,ASSESSMENT:, I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:, Change to Zyrtec 10 mg samples were given. He is not using nasal spray, but he has some at home. He should restart this. Continue to watch his peak flows to make sure his asthma does not come under poor control. Call if any further problems.general medicine, allergic rhinitis, sinus infection, sinus congestion, congestion, sinus
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1381
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CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:, Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle.,REVIEW OF SYSTEMS:, He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising.,MEDICATIONS:, No daily medications.,ALLERGIES:, Cefzil.,IMMUNIZATIONS:, His immunizations are up to date.,PHYSICAL EXAMINATION:,General: He is alert and in no distress, afebrile.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Tanner III.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. No rashes.,Hearing: Grossly normal.,ASSESSMENT:, Well child.,PLAN:, Anticipatory guidance for age. He is to return to the office in one year.nan
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{
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"dataset_name": "medical-transcription-4",
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PREOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,OPERATIVE PROCEDURE:,1. Placement of a Port-A-Cath.,2. Fluoroscopic guidance.,ANESTHESIA:, General LMA.,ESTIMATED BLOOD LOSS:, Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy. Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed. The patient was taken to the operating room, placed in supine position. General LMA anesthesia was administered. She is prepped and draped in the usual sterile fashion. She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire. Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava. The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery. A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements. The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer. Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch. Heparin flush was used to flush the port. Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition. All counts were reported as correct and I was present for the entire procedure.surgery, anal cancer, fluoroscopic, fluoroscopy, iv access, port-a-cath, trendelenburg position, chemotherapy, subclavian vein, port a cath, subcutaneous tissues, insertion, subclavian
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
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PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction. The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,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 return home in satisfactory condition.ophthalmology, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1384
}
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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_4",
"dataset_name": "medical-transcription-4",
"id": 1385
}
|
PREOPERATIVE DIAGNOSIS:, Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE: ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.ophthalmology, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1386
}
|
PREOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1. Epidermal autograft on Integra to the back (3520 cm2).,2. Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:, One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities. He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands. His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1. Variable take of Integra, particularly centrally and inferiorly on the back. A fair amount of lost Integra over the upper back and shoulders.,2. No evidence of infection.,3. Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:, The patient was brought to the operating room and positioned supine. General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed. He was then repositioned prone and perioperative IV antibiotics were administered. He was prepped and draped in the usual sterile manner. All staples were removed from the Integra and the adherent areas of Silastic were removed. The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution. Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads. Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome. These grafts were passed to the back table where they were meshed 3:1. The donor sites were hemostased using epinephrine-soaked Telfa and lap pads. Once all the grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment. We were happy with the lie of the grafts and they were stapled into place. The grafts were then overlaid with Conformant 2, which was also stapled into place. Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment. Allograft was thawed and meshed 1:1. It was then brought up onto the field, trimmed to fit and stapled into place over the wound. Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied. Donor sites on his buttocks were dressed in Acticoat and secured with staples. He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications. He was transported to PACU in stable condition.surgery, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1387
}
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REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint. The patient complains of fatigue, nausea, vomiting and fever. The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement. The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked. The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem. At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed. As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work". The patient has had dialysis since January secondary to hypertension-induced renal failure. He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center. He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago. The patient's history at this point is a little sketchy; however, he states that he left AMA. All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years. No alcohol, occasional marijuana, and no IV drug use. He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs: In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air. General: This is an alert and oriented African-American male x3 and in no acute distress. The patient is extremely lethargic and had to be aroused multiple times to answer questions. Mucous membranes are moist. HEENT: Head is normocephalic and atraumatic. There is no scleral icterus noted. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Cardiovascular: Shows a heart rate that is regular with a laterally displaced point of maximum intensity. There is no murmur, gallop, or rub noted. Lungs: Clear to auscultation bilaterally. No wheeze, rhonchi or rales. Abdomen: Soft, nontender and nondistended. Bowel sounds are present. Extremities: Show left forearm with an incision that is well healed from a left AV fistula. There is a distal thrill palpable and there is some tenderness over the incisional area. There is no erythema or pus noted. Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131. Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1. Nonfunctional AV fistula.,2. End-stage renal disease.,3. Hypertension.,4. Status post MI.,5. Clogged PermCath.,PLAN:,1. Give the patient TPA to the shunt, PermCath in both feet.,2. To board for Tuesday for shunt repair if needed.,3. To dialyze as soon as possible.,4. To review previous operative report.,5. The patient will be contacted in the morning and told whether to go to dialysis or not.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1388
}
|
PROTOCOL:, Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:, Chest pain.,PROCEDURE AND INTERPRETATION: ,1. Baseline heart rate: 67.,2. Baseline blood pressure: 150/86.,3. Total time: 6 minute 51 seconds.,4. METs: 10.1.,5. Peak heart rate: 140.,6. Percent of maximum-predicted heart rate: 90.,7. Peak blood pressure: 200/92.,8. Reason test terminated: Shortness of breath and fatigue.,9. Estimated aerobic capacity: Average.,10. Heart rate response: Normal.,11. Blood pressure response: Hypertensive.,12. ST segment response: Normal.,13. Chest pain: None.,14. Symptoms: None.,15. Arrhythmia: None.,CONCLUSION:,1. Average aerobic capacity.,2. Normal heart rate and blood pressure response to exercise.,3. No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION: ,The patient was discharged home and was asymptomatic.,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1389
}
|
HISTORY: , The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD. The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease. The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall. The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:, As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss. No history of sore throat. No history of any ascites. No history of nausea, vomiting, or diarrhea. No black stools. No history of any rash. No back pain. No leg pain. No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:, He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT: The patient is atraumatic and normocephalic. Pupils are equal and reactive to light. Extraocular muscles are intact.,NECK: Supple. No JVD and no thyromegaly.,HEART: S1 and S2 heard. No murmurs or extra sounds.,ABDOMEN: Distention of the abdomen present.,EXTREMITIES: No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34. PT, PTT, and INR is normal. Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's. Potassium is 5.3, BUN of 39, and creatinine of 1.9. Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN: ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis. The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy. We will do urine for cytology. We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels. We will send a PSA level and if needed may be a urology consult.consult - history and phy., mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1390
}
|
SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper. Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:, The patient and her daughter completed both days of diabetes education in a group setting. Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician. Fasting blood sugars are 127, 80, and 80. Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63. Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109. Assessment of her knowledge is completed at the end of the counseling session. She demonstrated increased knowledge in all areas and had no further questions. She also completed an evaluation of the class.,The patient's feet were examined during the education session. She had flat feet bilaterally. Skin color was pink, temperature warm. Pedal pulses 2+. Her right second and third toes lay on each other. Also, the same on her left foot. However, there was no skin breakdown. She had large bunions, medial aspect of the ball of both feet. She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care. First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels. Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control. Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control. Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:, Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness. She is to followup with Dr. XYZ for possible reduction in her insulin doses.soap / chart / progress notes, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1391
}
|
PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS: ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:, Local with sedation.,INDICATION:, The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids. The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.ophthalmology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1392
}
|
PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS: ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a dual-chamber pacemaker.,2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Versed 2.5 mg.,2. Fentanyl 150 mcg.,3. Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2. Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3. Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Completion of the course of antibiotics.,4. Home dismissal instructions provided in written format.,5. Device interrogation in the morning.,6. Wound check in 7 to 10 days.,7. Enrollment in device clinic.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1393
}
|
ADENOIDECTOMY,PROCEDURE:, The patient was brought into the operating room suite, anesthesia administered via endotracheal tube. Following this the patient was draped in standard fashion. The Crowe-Davis mouth gag was inserted in the oral cavity. The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril. Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer. The adenoid pad was removed without difficulty. The nasopharynx was packed. Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated. The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.ent - otolaryngology, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: 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_4",
"dataset_name": "medical-transcription-4",
"id": 1394
}
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PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:, A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained. The patient was noted to have irregular contractions. She was given 1 dose of subcutaneous terbutaline which resolved her contraction. A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation. There was noted to be adequate fluid. Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained. Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring. Following successful external cephalic version, the patient was placed on continuous external fetal monitoring. She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version. She did not have regular contractions and therefore she was felt to be stable for discharge to home. She was given appropriate labor instructions.obstetrics / gynecology, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1395
}
|
PREOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:, Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:, General.,HISTORY: , The patient is 5-1/2 years old. She is here this morning with her Mom. She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well. At the office we saw the tonsils were very big. There was a rock in the right ear and it was very deep in the canal, near the drum. We will remove the foreign body under the same anesthetic.,PROCEDURE:,: Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B. I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum. On the right side, I took out some impacted wax and removed the rock with a large suction. It was actually resting on the surface of the drum but had not scarred or damaged the drum. The drum was intact with no evidence of middle ear fluid. The microscope was set aside. Afrin drops were placed in both nostrils. The neck was gently extended and the Crowe-Davis mouth gag inserted. The tonsils and adenoids were very large. The uvula was intact. Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx. Tonsillectomy accomplished by sharp and blunt dissection. Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine. Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds. Sponge is removed from the nasopharynx. The suction electrocautery was used for pinpoint hemostasis on the adenoid bed. We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices. The nose and throat were then irrigated with saline and suctioned. Excellent hemostasis was observed. An orogastric tube was placed. The stomach found to be empty. The tube was removed, as was the mouth gag. Sponge and needle count were reported correct. The child was then awakened and prepared for her to return to the recovery room. She tolerated the operation excellently.surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1396
}
|
PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence. Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations. The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:, This patient was brought to the operating room, a general anesthetic was administered. She was placed in dorsal lithotomy position. Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution. She was draped in usual sterile fashion. A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder. Two Allis clamps were placed over the mid urethra. This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution. Two areas suprapubically on either side of midline were injected with the same anesthetic solution. The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra. Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus. The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally. The Foley catheter was removed. A cystoscopy was performed using a 70-degree cystoscope. There was noted to be no violation of the bladder. The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions. The mesh was snugged up against a Mayo scissor held under the mid urethra. The overlying plastic sheaths were removed. The mesh was cut below the surface of the skin. The skin was closed with 4-0 Plain suture. The vaginal vault was closed with a running 2-0 Vicryl stitch. The blood loss was minimal. The patient was awoken and she was brought to recovery in stable condition.urology, stress urinary incontinence, foley catheter, metzenbaum scissor, sparc, sparc mesh, bladder, orifice, perineum, sling, suburethral, ureteral, urethral hypermobility, vagina, vaginal vault, vulva, cystoscopy, suburethral sling, stress urinary, urinary incontinence, incontinence
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1397
}
|
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 weeks.,2. History of previous cesarean section x2. The patient desires a repeat section.,3. Chronic hypertension.,4. Undesired future fertility. The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 weeks.,2. History of previous cesarean section x2. The patient desires a repeat section.,3. Chronic hypertension.,4. Undesired future fertility. The patient desires permanent sterilization.,PROCEDURE PERFORMED: ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:, 800 mL.,COMPLICATIONS: ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term. The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization. The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie. The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted. The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. The placenta was delivered spontaneously 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. Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology. Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected. Hemostasis was visualized bilaterally. The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic. The uterine incision was reexamined and it was noted to be hemostatic. The pelvis was copiously irrigated. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.surgery, bilateral tubal ligation, permanent sterilization, undesired future fertility, repeat cesarean section, intrauterine pregnancy, mayo scissors, kocher clamps, metzenbaum scissors, fallopian tube, babcock clamp, pomeroy method, rectus muscles, cesarean section, intrauterine, cesarean,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1398
}
|
CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:, All other systems reviewed & are negative.,PAST MEDICAL HISTORY:, Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulatesnan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1399
}
|
PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma. Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma. This area is to be excised accordingly and closed. We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table. Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision. The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology. Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly. Final margins were clear.,Closure consisted of undermining circumferentially. Advancement closure with dog ear removal distally and proximally was accomplished without difficulty. Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:, The 2.6 mm loupe magnification was utilized throughout the procedure. No complications noted with excellent and all clear margins at the termination. An advancement closure technique was utilized.hematology - oncology, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal
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