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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1800
}
|
PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:, Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:, No evidence of intramediastinal purulence or hematoma. He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. The previously placed AlloDerm membrane was removed. Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. Both cavities were also irrigated and suctioned. The drains were flushed and repositioned. Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. The sternum was then smeared with a vancomycin paste. The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. The skin was closed with interrupted nylon sutures and a sterile dressing was placed. The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1801
}
|
PREOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell. He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy. This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula. All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given. This was done under monitored anesthesia care. He was prepped and draped in the usual sterile fashion. He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery. Incision was deepened down through the subcutaneous fascia. The vein was identified, dissected for a good length, and then the artery was identified and dissected. Heparin 5000 units was given. The artery clamped proximally and distally, opened up in the middle. It was found to have Monckeberg's arteriosclerosis of a moderate intensity. The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down. Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.surgery, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1802
}
|
COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1803
}
|
REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1804
}
|
GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC: Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY: Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL: Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY: Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY: Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC: Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC: Negative for any abnormal bruising, frequent infections or bleeding.office notes, review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1805
}
|
CHIEF COMPLAINT:, Chronic otitis media.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:, None.,MEDICATIONS:, None.,FAMILY HISTORY:, Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:, None.,SOCIAL HISTORY: , The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:, The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.consult - history and phy., chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1806
}
|
CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow.",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.radiology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1807
}
|
CHIEF COMPLAINT:, Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. Again, she is scheduled for mastectomy in two weeks. She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. There was no dilation of the right ureter noted. Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:, Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:, None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, She is retired. Does not smoke or drink.,REVIEW OF SYSTEMS:, I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:, Please see the physical exam sheet I completed. Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria. She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005. I will try to obtain the report to see if the right kidney was evaluated at that time. She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney. She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. She will call us back to schedule the x-rays. She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. There is also a question of a stone present in the kidney. She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.nephrology, hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1808
}
|
PROCEDURES PERFORMED,1. Insertion of subclavian dual-port Port-A-Cath.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good conditionsurgery, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: 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": 1809
}
|
COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:, The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability. He is a 43-year-old married, white male who came unaccompanied to the evaluation. He drove himself suggesting that he drives regularly. He reportedly has been on Disability since around 2002. He was a good historian, freely offering information. He was dressed and groomed casually, yet neat and appropriate in appearance. He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning. No censorship of data was indicated. ,PRESENT PROBLEMS:, The claimant described his recent problems as, "serious depression. Very hard to concentrate. Very short tempered. Usually distracted." ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago. He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because "I had a breakdown and ended up in the hospital. They said that I wasn't reliable enough and laid me off." Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed. ,The claimant has had significant emotional problems since around 1997. He was first hospitalized in that year and has been hospitalized five more times since then. The last hospitalization was last month in Atlanta, Georgia. He has tried to overdose in the past as well as cut his wrist. He even had to undergo electroconvulsive therapy in 2001, because of depression. He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident. Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d. He is not involved in outpatient therapy. ,PERSONAL, FAMILY AND SOCIAL HISTORY:, The claimant indicated that he graduated from high school in regular classes. He did have to repeat the kindergarten because he was too young. He worked for about 10 years at a company in Massachusetts. He was not advancing on that job and therefore quit. He has had three subsequent jobs and a number of emotional problems since. He indicated usually getting along with others but stated, "I had trouble taking direction from someone younger than me. I resent getting nagged at. I'd get angry or just seethe." He has been let go from his last two jobs because of emotional issues. ,The claimant was married the first time for five years. He has no children. He now lives at home with his wife., ,The claimant denied any legal problems. He suggested that his mother had bipolar disorder. He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs. He stopped drinking in 1997. Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:, The claimant described his typical day as follows, "I usually get up about 7:00 to 7:30. Have breakfast. Take a shower about 8:30. Do errands. Me and my wife are out of the house by 9:00. Check e-mail at the library. I like the computer. We have lunch 11:30 or 12:00. Do errands or watch talk shows or I'll read. I love to read. Around 5:00 to 5:30, have supper. Watch the news, game shows. In bed by 10:00." He will help with vacuuming, doing the dishes or yard work. His wife does most of the house cleaning. He does no cooking. He and his wife get out every day usually for three or four hours. He has a neighbor next door that he will see twice a week. He used to go to the gym but has not been in a few weeks. No other family contact was described and he does not go to church. When asked what he enjoys he stated, "read, use my computer or go ride my bike.", ,MENTAL STATUS EVALUATION:, On interview, the claimant looked his stated age of 43 years. He was tall in stature and thin in weight. He was neat and clean in appearance. Posture was somewhat tense but psychomotor activity was not remarkable. Eye contact was fleeting with fair social skills evident. Facial expression was tense and affect was restricted with little animation noted. General mood appeared dysphoric. Speech was clear, coherent, logical, goal-directed and relevant. He was cooperative in attitude toward the examiner. He described his recent mood as, "cloudy, gray because we've got a lot of personal problems right now. I'm frustrated because I don't know where things are going." He described some problems with falling asleep and staying asleep at night as well as decreased energy level. He denied appetite disturbance. He has lost interest in some activities suggesting mild anhedonia. He has trouble with attention and concentration stating, "I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder." He has thoughts of suicide about once or twice a week and has often fled situations in the past. He stated, "I try to keep myself from running away." He denied any plan or intent for suicide. He suggested significant anxiety problems as well. He stated, "I'm dealing with pedophilia. I try to time it so that I don't go to a store with lots of people around. If there is people I get real edgy, heart pounds, shortness of breath. A lot of chest discomfort." He has these panic symptoms quite regularly and they have occurred ever since 1997. That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail. No phobic processes were suggested. No psychotic symptoms were revealed. He denied hallucinations and no delusional material was elicited. Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres. He evidenced adequate memory for both recent and remote events. He was able to recall 3 of 3 words after a 1 minute and 10 minute delay. Fair sustained attention and concentration skills were shown. He was able to spell a word backward and performed a serial 7 subtraction task affectively. Basic calculation skills were intact and no language-based dysfunction was noted. Social judgment was also intact as he gave a good response to finding a wallet in the street, "find who the owner was, bring it to the police station or contact the person," and to seeing smoke in a theater, "Get a hold of staff so they could evacuate." Adequate conceptual abilities was shown with similarity comparisons. Somewhat limited abstraction was shown with proverb interpretation, glass houses, "don't do anything you're not supposed to do." Premorbid intellect is estimated to be at least in the average range. Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I: Major Depression, recurrent, moderate. Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:, Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities. He continues to show significant problems with depression and anxiety. He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations. He relies on his wife to take care of most all household task. He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:, The claimant was strongly encouraged to get some additional help for his emotional problems. He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1810
}
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EXAM: ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS: ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. An additional lateromedial projection of the right breast was obtained. The breasts demonstrate heterogeneously-dense fibroglandular tissue. Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter. No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen. Multiple additional benign-appearing calcifications are visualized bilaterally. Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder. This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow. This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter. At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast. Informed consent was obtained. The lesion was re-localized under ultrasound guidance. The left breast was prepped and draped in the usual sterile fashion. 2% lidocaine was administered locally for anesthesia. Additional lidocaine with epinephrine was administered around the distal aspect of the lesion. A small skin nick was made. Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides. The lateral to medial approach was performed with an 11-gauge Mammotome device. The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture. Two core biopsies were obtained. The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma. Arterial blood was visualized exiting the access site. A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage. Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved. Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter. The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast. The patient was observed in the ultrasound department for the following 30 minutes without complaints. The patient was subsequently discharged with information and instructions on utilizing the ice bandage. The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1. A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained. Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma. Pressure was applied until hemostasis was achieved. The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition. The core biopsies were submitted to pathology for further analysis.,2. Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3. Suspicious mammographic findings. The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied. Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.obstetrics / gynecology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1811
}
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PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia. A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS: ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME: ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:, The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does toe walk. Given his tightness, surgery versus observation was recommended to the family. Family however wanted to correct his toe walking. Surgery was then discussed. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems. All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered. The patient received Ancef preoperatively. The patient was then subsequently placed prone with all bony prominences padded. Two bilateral nonsterile tourniquets were placed on each thigh. Both extremities were then prepped and draped in a standard surgical fashion. We turned our attention first towards the left side. A planned incision of 1 cm medial to the Achilles tendon was marked on the skin. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Incision was then made and carried down through subcutaneous fat down to the tendon sheath. Achilles tendon was identified and Z-lengthening was done with the medial distal half cut. Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked. This was trimmed to obtain an end-on-end repair with 0 Ethibond suture. This was also oversewn. Wound was then irrigated. Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat. The skin was closed using 4-0 Monocryl. Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine. It was then dressed with 4 x 4 and Webril. Tourniquet was released at 30 minutes. The same procedure was repeated on the right side with tourniquet time of 21 minutes. While the patient was still prone, two short-leg walking casts were then placed. The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN: ,The patient will be discharged on the day of surgery. He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks. He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months. The patient may or may not need physical therapy while his Achilles lengthenings are healing. The patient is not to participate in any PE for at least 6 months. The patient is given Tylenol No. 3 for pain.surgery, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative,
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{
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"dataset_name": "medical-transcription-4",
"id": 1812
}
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PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:, Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.surgery, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1813
}
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TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula. She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein. She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P. She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T. She lives with her husband and she also has a son at home and she is a very active lady. She is right handed. The plan was to place an AV fistula at the left wrist. The risks and benefits were fully explained to her. She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically. Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist. The cephalic vein was exposed. The superficial branch of the radial artery was carefully protected and the radial artery was exposed. There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture. There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery. There were no complications.nephrology, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1814
}
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PREOPERATIVE DIAGNOSIS:, Perirectal abscess.,POSTOPERATIVE DIAGNOSIS:, Perirectal abscess.,PROCEDURE: , Incision and drainage (I&D) of perirectal abscess.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room after obtaining an informed consent. A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.,Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope. I found some small internal hemorrhoids and no fistulous tracts.,Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained. All necrotic tissue was debrided. The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area. The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.,Estimated blood loss was minimal. The patient tolerated the procedure well and was sent for recovery in satisfactory condition.surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1815
}
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EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:, Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION: ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,podiatry, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1816
}
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SUBJECTIVE: , I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day. The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals: As in chart. The patient is alert, pleasant, and cooperative. She is in no apparent distress. The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone. We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. Basically thereafter, over time, I may try to sneak it back a little bit further. She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D. We will arrange to have a CBC drawn weekly.,hematology - oncology, platelets, platelet count, thrombocytopenia, prednisone,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1817
}
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IDENTIFICATION OF PATIENT: , This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian.,CHIEF COMPLAINT:, "I'm bipolar and I have severe anxiety disorder. I have posttraumatic stress syndrome." ,HISTORY OF PRESENT ILLNESS: , At age 19, Ms. Abc had a recurrence of memories. Her father had molested her, and the memories returned. In 1992, at the age of 18, she entered her first abusive marriage. She was beaten and her husband shared her sexually with his friends. This lasted until age 24. The second marriage was age 26, her second husband was a drug abuser and "he slapped me around." She had two children during that marriage. In 2001, she was married in Indiana to a military man. This was her third marriage and she stated, "This marriage is good." She had EMDR in Indiana when she was being treated for Posttraumatic Stress Disorder. ,Historically, her first husband threw her down the stairs at age 21, and she had a miscarriage. Her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have. Currently, she is unable to have sex with the lights on. She states, "Sometimes I hurt all over." Her husband was deployed three days ago, on April 21, to a foreign theater of operations. She has panic attacks every day.,Review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells Old Spice aftershave. She does not avoid thoughts of her trauma, but she avoids the perpetrators and placements. She is not unable to recall details of her trauma. She does feel detached and isolated. She has restrictive range of affect and she had a foreshortened future. She also had a loss of interest in things, starting at age 5. She has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, "I don't do as good as I can." Further review of symptoms shows her to have periods of constant cleaning and increased sex drive. She also has had euphoria, poor judgment, distractibility, and inability to concentrate. She has been irritable. She has had a decreased need for sleep, which lasts for six or seven days. She had racing thoughts, rapid speech, but has not had grandiosity. These symptoms of mania occurred in the last week of November 2005 and lasted for seven days from, which she was not hospitalized. Furthermore, she endorses the following symptoms: She states, "When I'm depressed, I have neck pain, jaw pain, abdominal pain. I have migraines and urinary tract pain." She also complains of chest pain, pain during sex, and excess pain during her menstrual period. She has an increased gag reflex, which has caused her to have emesis. She states it is easy to choke. She has had physical symptoms, "for as long as I can remember," and she states, "I've felt like crap most of my life," "it affects my marriage." She has also admitted to having nausea and vomiting, with excess gas. She has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea. She states that sex is only important to her in mania. Otherwise, she has no desire. She has had irregular periods for two or three weeks at a time. She has had no episodes of excess bleeding. She has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion. Currently, she is sleeping from 10 p.m. to 3 a.m., and that is under the influence of Lunesta. Her energy is "not good. Her appetite is "I'm craving crap," stating that she wants to eat carbohydrates. Concentration is poor today. She feels worthless, hopeless, and guilty. Her self-esteem is "I don't have any." She has no anhedonia, and she has no libido. She also has had feelings of chronic emptiness. She feels abandoned. She has had unstable relationships. She self-mutilated, but she stopped at age 22. She has trouble controlling her anger. She did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child. She has no identity disturbance. ,CURRENT MEDICATIONS: , Seroquel 700 mg p.o. q.d.; Wellbutrin XL 300 mg p.o. q.d.; Desyrel 100 mg p.o. q.h.s.; Ativan p.r.n. dosage unknown. In the past, she has been on Prozac, Paxil, lithium, Depakote, Depakene, and Zoloft. ,PSYCHIATRIC HISTORY: , She saw Dr. B. She saw Chris. She is diagnosed with Posttraumatic Stress Disorder, depression, and Bipolar Disorder. She had counseling in Indiana in 2001. She had inpatient treatment in Indiana in 2001 also, at age 19. She had three suicide attempts. At age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more. She has had no psychological testing. ,MEDICAL HISTORY: , Significant for migraines, hyperactive and gag reflex. She states she has had cardiovascular workups due to panic disorder, but nothing was found. She also has astigmatism. She states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy. She has no history of head injury or MRI test of the brain. No history of EEG, seizures, thyroid problems, or asthma. There are no drug allergies. She has never had an EKG. She does have musculoskeletal problems and has arthritis-like joint pains on occasion. She has had ear infections and sinus infections intermittently. Hearing test was normal. She is currently not pregnant. She saw her gynecologist four months ago at Elmendorf Air Force Base. ,Surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19. She had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown. ,She has no hypertension, no diabetes, no glaucoma.,FAMILY HISTORY: , Significant for her paternal grandmother not being mentally competent. Her mother was depressed and was treated. Her mother is currently age 55. She has a paternal grandmother who may have had Schizophrenia. There is also a family history of the paternal grandfather using substance. He was "an extreme alcoholic." She had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess. The maternal uncle committed suicide; he drowned himself. ,There is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, Tourette's syndrome, or learning disabilities. ,Medical history in the family is significant for her son, age 4, who is having seizures ruled out. Her mother and two maternal aunts have thyroid disease. She has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer. There is no family history of hypertension.,ABUSE HISTORY: , Significant for being physically abused by her father, her first husband, and her second husband. She was sexually abused by her father from age 5 to age 18. She states, "my first husband gave me away for four years to his friends to be used sexually." She was emotionally abused by her mother, father, and both of her first two husbands. She was neglected by her mother and her father. She never witnessed domestic violence. She has not witnessed traumatic events. ,SUBSTANCE ABUSE: , Significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early. She has never used alcohol, tobacco, marijuana, or any other drugs.,PARENT/SIBLING RELATIONSHIP INFORMATION: , She had had a poor relationship with her parents. She has no contact with them. She has no contact with her brother. She was married three times, as stated in the history. She has two children with Asperger's and autism. ,HOBBIES/SPIRITUAL: , She likes to read and write. She likes to cross-stitch, quilt, and do music, and has found a good church in Anchorage. ,EDUCATIONAL:, She states she was teased in school because "I was so depressed." She got good grades otherwise. She finished high school.,WORK HISTORY:, She has worked in the past managing a Dollar General store. She has been a waitress and an executive secretary. ,LEGAL HISTORY:, She has never been arrested.,MENTAL STATUS:, Significant for a well groomed, well kempt young white female who appears her stated age. She has a pierced nose and has a nose ring. She is cooperative, alert, and attentive. She makes good eye contact. Her speech is normal, prosody is normal, and rate and rhythm are normal. Motor is normal. She has no gait abnormalities. No psychomotor retardation or agitation. Her mood is "I'm sad and depressed." Her affect is restricted. She is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews. Perception is normal. She denies auditory and visual hallucinations. She denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred. Otherwise, she has not had dissociative phenomena. Thought processes are normal. She has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality. She is goal directed and oriented. Insight and judgment are good. She is alert and oriented to person, place, and time, stating it was 04/18/06, Tuesday, it was Anchorage in the spring. She is able to register three words and recall them at five minutes. She is able to do simple calculations, stating 2x3 is 6, and 1 dollar 15 cents has 23 nickels. She is given a proverb to interpret. She was asked what judging a book by its cover meant. She said, "You can't always tell what a person is by looking at them on the outside." She is appropriate in her abstraction, and is able to identify the last four presidents.,CLINICAL IMPRESSION: ,Abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis. She has had an extensive history of sexual abuse and emotional abuse. She has not used drugs and alcohol, and she has been treated in the past. She was treated with EMDR and stated that she did not benefit from that. She has an extensive medical history and brought her medical records, and they were thoroughly reviewed. She currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in November of 2005. She also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania. Medical records review a history of dysmenorrhea with surgery to the right cystic ovary. The EMDR did not benefit her in the past. She also has not had good psychotherapeutic consultation. ,DIAGNOSES:,AXIS I. 309.81 Posttraumatic Stress Disorder.nan
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{
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"dataset_name": "medical-transcription-4",
"id": 1818
}
|
HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.,EYES: Conjunctivae are now pink.,ENT: Oropharynx is clear.,CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.,LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN: Soft and nontender with no organomegaly appreciated.,EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.,NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:, Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.soap / chart / progress notes, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1819
}
|
REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1. Diabetes type II.,2. High blood pressure.,3. High cholesterol.,4. Acid reflux disease.,5. Chronic back pain.,PAST SURGICAL HISTORY:,1. Lap-Band done today.,2. Right foot surgery.,MEDICATIONS:,1. Percocet on a p.r.n. basis.,2. Keflex 500 mg p.o. t.i.d.,3. Clonidine 0.2 mg p.o. b.i.d.,4. Prempro, dose is unknown.,5. Diclofenac 75 mg p.o. daily.,6. Enalapril 10 mg p.o. b.i.d.,7. Amaryl 2 mg p.o. daily.,8. Hydrochlorothiazide 25 mg p.o. daily.,9. Glucophage 100 mg p.o. b.i.d.,10. Nifedipine extended release 60 mg p.o. b.i.d.,11. Omeprazole 20 mg p.o. daily.,12. Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning. She woke up at home this evening with massive swelling of the left side of the tongue. The patient therefore came to the emergency room for evaluation. The patient was almost intubated on clinical grounds. Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL: The patient denies any itching of the skin or urticaria. She has not noticed any new rashes. She denies fever, chill, or malaise.,HEENT: The patient denies vision difficulty.,RESPIRATORY: No cough or wheezing.,CARDIOVASCULAR: No palpitations or syncopal episodes.,GASTROINTESTINAL: The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY: ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS: On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6. O2 saturation was 95% on room air.,HEAD AND NECK: Face is symmetrical. Tongue is still swollen, especially on the left side. The floor of the mouth is also indurated. There is no cervical lymphadenopathy. There is no stridor.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.,ABDOMEN: Benign.,EXTREMITIES: There is no swelling.,NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1820
}
|
SUBJECTIVE:, The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. She has had it for about a year, but seems to be worsening. She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot. They are not worse with walking. It seems to be worse when she is in bed. There is some radiation of the pain up her leg. She also continues to have bilateral shoulder pains without sinus allergies. She has hypothyroidism. She has thrombocythemia, insomnia, and hypertension.,PAST MEDICAL HISTORY:, Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002. She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004. She has had a number of colonoscopies; next one is being scheduled at the end of this month. She also had a right total knee arthroplasty in 1993. She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004.,ALLERGIES: , Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine.,CURRENT MEDICATIONS:, Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n.,SOCIAL HISTORY:, She is a nonsmoker and nondrinker. She has been widowed for 18 years. She lives alone at home. She is retired from running a restaurant.,FAMILY HISTORY:, Mother died at age 79 of a stroke. Father died at age 91 of old age. Her brother had prostate cancer. She has one brother living. No family history of heart disease or diabetes.,REVIEW OF SYSTEMS:,General: Negative.,HEENT: She does complain of some allergies, sneezing, and sore throat. She wears glasses.,Pulmonary history: She has bit of a cough with her allergies.,Cardiovascular history: Negative for chest pain or palpitations. She does have hypertension.,GI history: Negative for abdominal pain or blood in the stool.,GU history: Negative for dysuria or frequency. She empties okay.,Neurologic history: Positive for paresthesias to the toes of both feet, worse on the right.,Musculoskeletal history: Positive for shoulder pain.,Psychiatric history: Positive for insomnia.,Dermatologic history: Positive for a spot on her right cheek, which she was afraid was a precancerous condition.,Metabolic history: She has hypothyroidism.,Hematologic history: Positive for essential thrombocythemia and anemia.,OBJECTIVE:,General: She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs: Her age is 81. Temperature: 98.0. Blood pressure: 140/70. Pulse: 72. Weight: 127.,HEENT: Head was normocephalic. Pupils equal, round, and reactive to light. Extraocular movements are intact. Fundi are benign. TMs, nares, and throat were clear.,Neck: Supple without adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur, click, or rub. No carotid bruits are heard.,Abdomen: Normal bowel sounds. It is soft and nontender without hepatosplenomegaly or mass.,Breasts: Surgically absent. No chest wall mass was noted, except for the Port-A-Cath in the left chest. No axillary adenopathy is noted.,Extremities: Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities. There is a cyst on the anterior portion of the right ankle. Pedal pulses were present.,Neurologic: Cranial nerves II-XII grossly intact and symmetric. Deep tendon reflexes were 1 to 2+ bilaterally at the knees. No focal neurologic deficits were observed.,Pelvic: BUS and external genitalia were atrophic. Vaginal rugae were atrophic. Cervix was surgically absent. Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.,Rectal: Exam confirmed there is brown stool present in the rectal vault.,Skin: Clear other than actinic keratosis on the right cheek.,Psychiatric: Affect is normal.,ASSESSMENT:,1. Peripheral neuropathy primarily of the right foot.,2. Hypertension.,3. Hypothyroidism.,4. Essential thrombocythemia.,5. Allergic rhinitis.,6. Insomnia.,PLAN:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1821
}
|
PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally. The EEG background is symmetric. Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region. No clinical signs of involuntary movements are noted during synchronous video monitoring. Recording time is 22 minutes and 22 seconds. There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded. No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently. Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:, EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region. The EEG findings are consistent with potentially epileptogenic process. Clinical correlation is warranted.sleep medicine, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: 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": 1822
}
|
SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food diary. I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern. I encouraged her to continue all of this.,ASSESSMENT:, The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. She needs to continue all this.,PLAN:, Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.soap / chart / progress notes, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1823
}
|
1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2. The left atrium appears mildly dilated.,3. The right atrium and right ventricle appear normal.,4. The aortic root appears normal.,5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.,8. The pulmonary valve appears normal with trace pulmonary insufficiency.,9. There is no pericardial effusion or intracardiac mass seen.,10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,radiology, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1824
}
|
PREOPERATIVE DIAGNOSES:,1. Chondromalacia patella.,2. Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1. Grade-IV chondromalacia patella.,2. Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with partial chondroplasty of patella.,2. Lateral retinacular release.,3. Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:, General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella. There was a grade II to III chondral changes to the patellar groove. The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle. The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen. The articular surfaces and the remainder of the knee appeared intact. Cruciate ligaments also appeared intact to direct stress testing.,HISTORY: ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain. She has been diagnosed in the past with chondromalacia patella. She has failed conservative therapy. It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint. She elected to proceed with the surgical intervention. All risks and benefits of the surgery were discussed with her. She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital. She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department. Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion. A stab incision was made in inferolateral and parapatellar regions. Through this the cannula was placed and the knee was inflated with saline solution. Intraoperative pictures were obtained. The above findings were noted. Second portal site was initiated in the inferomedial parapatellar region. Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris. Next, the camera was placed through the inferomedial portal. An arthroscopic Bovie was placed through the inferolateral portal. A release of lateral retinaculum was then performed using the Bovie. Hemostasis was controlled with electrocautery. Next, the knee was suctioned dry. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. An oblique incision was made along the medial parapatellar region of the knee. The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery. The retinaculum was then incised in line with the incision. The patellar tendon was identified. The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris. Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact. The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle. It was then held in place with a Steinmann pin. Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle. There was excellent fixation noted. The Q-angle was noted to be decreased to approximately 15 degrees. She was transferred approximately 1 cm in length. The wound was copiously irrigated and suctioned dry. The medial retinaculum was then plicated causing further medialization of the patella. The retinaculum was reapproximated using #0 Vicryl. Subcuticular tissue were reapproximated with #2-0 Vicryl. Skin was closed with #4-0 Vicryl running PDS suture. Sterile dressing was applied to the lower extremities. She was placed in a Donjoy knee immobilizer locked in extension. It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet. She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint. She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.surgery, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1825
}
|
PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS: ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:, IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite. After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus. A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus. The first, second, and third portions of the duodenum were normal. The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori. The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia. The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone. The scope was then removed throughout the esophagus which was normal. The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.surgery, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1826
}
|
PREOPERATIVE DIAGNOSIS:, Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for. The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap. He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty. After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty. He had previously undergone a CT scan. Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed. We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant. He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis. The scalp was prepped and draped in the usual sterile fashion. A previous incision was reopened and the scalp flap was reflected forward. We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap. We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base. We did explore laterally and saw a little bit of the mesh on the lateral orbit. Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws. We had achieved good hemostasis. The wound was closed in multiple layers in usual fashion over a Blake drain. At the end of the procedure, all sponge and needle counts were correct. A sterile dressing was applied to the incision. The patient was transported to the recovery room in good condition after having tolerated the procedure well. I was personally present and scrubbed and performed/supervised all key portions.neurosurgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1827
}
|
PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1. Left adrenal mass, 5.5 cm.,2. Intraabdominal adhesions.,PROCEDURE PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:, None.,DISPOSITION:, The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:, This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1828
}
|
EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE: ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age. There are no extraaxial fluid collections. There is no hydrocephalus/midline shift. Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits. The normal vascular flow volumes are maintained. The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain. Specifically, no findings to explain the patient's headaches are identified.radiology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1829
}
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PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:, IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion. The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes. The patient has failed to conservative treatment and desires surgical correction at this time. Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:, After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously. The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection. Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection. After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg. The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot. After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon. Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery. A neurovascular bundle was identified and reflected medially. Laterally the extensor hallucis longus tendon was identified and protected with retraction as well. Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully. The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule. The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree. Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx. Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint. The bone cortex was noted to be intact and in good condition. Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head. In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected. Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well. Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head. Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal. A second 0.45 K-wire was inserted proximally as well. Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral. After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made. This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal. Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone. Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially. The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone. Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction. Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit. The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex. Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved. Intramedullary sludge was noted to exit from the osteotomy cut. Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked. Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap. Following this, a 20 mm full threaded screw was inserted and tightened. Good intramedullary sludge was noted and compression was achieved. Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite. Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted. Based on this, a lateral release was performed. The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace. The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected. Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament. Upon completion of this, the hallux was noted to be in a rectus position with good alignment. The area was then flushed and irrigated with copious amounts of sterile saline. After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture. Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers. The skin was then reapproximated and closed using #5-0 Monocryl suture. Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing. The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg. The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot. The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit. Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain. The patient was also given prescription for clindamycin to be taken 300 mg four times a day. The patient was given surgical shoe and was placed in a posterior sling. The patient was given crutches and instructed to use them for ambulation. The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend. The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office. The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that. The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise. X-rays were taken and the patient was discharged home upon completion of this.orthopedic, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus
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PREOPERATIVE DIAGNOSIS:, Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth. ICD9 Code: 528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS: ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:, 40 Ml.,FLUID: ,700 mL of crystalloid.,COMPLICATIONS: ,None.,CONDITION: ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE: ,The patient is a 41-year-old that has a recent history of toothache and tooth pain. She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions. The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment. She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse. The patient was admitted to the hospital on Monday for IV antibiotics. Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain. The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery. It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room and laid on the operating room table on supine fashion. ASA monitors were attached as stated. General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space. This pus was then cultured and sent to micro lab for cultures and sensitivities. Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate. After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case. Mouth rinse was then poured into the oral cavity. The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction. Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space. It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay. Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5. It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed. Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed. The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file. Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed. This site was then irrigated with copious amounts of sterile water. There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct. A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed. A little-to-no pus was received. Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture. Remainder of the flap was left open to drain. Further examination of the floor of mouth was soft. The lateral pharynx was nonindurated or swollen. At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated. The procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition.dentistry, cultures, buccal, teeth, canine, pacu, teeth extractions, oromaxillary facial, facial surgery, buccal space, throat pack, buccal mucosa, surgical removal, canine's base, necrotic teeth, cpt code, infection, oral, surgery, mucosa, anesthesia, facial, pus, toothache,
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{
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"dataset_name": "medical-transcription-4",
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ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:, Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence. The patient seemed to be recovering well. The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload. The patient was given nebulizer treatment and Lasix increased the same to resolve the problem. The patient was comfortable, stabilized, breathing well. On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:, Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity. The patient is to continue CPM machine while in bed along with antiembolic stockings. The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:, Stable.orthopedic, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,
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{
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SUBJECTIVE:, The patient is well-known to me. He comes in today for a comprehensive evaluation. Really, again he borders on health crises with high blood pressure, diabetes, and obesity. He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc. He knows better and has been through some diabetes training. In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004. Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days. He has had elevated blood pressure. His other concerns include allergic symptoms. He has had irritable bowel syndrome with some cramping. He has had some rectal bleeding in recent days. Also once he wakes up he has significant difficulty in getting back to sleep. He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:, As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:, Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:, Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions: None.,PHYSICAL EXAMINATION:,VITAL SIGNS: As above.,GENERAL: The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear.,NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit.,CHEST: No chest wall tenderness or breast enlargement.,HEART: Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS: Clear to auscultation and percussion.,ABDOMEN: Significantly obese without any discernible organomegaly. GU: Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL: Smooth, nonenlarged prostate with just some irritation around the rectum itself. No hemorrhoids are noted.,EXTREMITIES: Some slow healing over the tibia. Without clubbing, cyanosis, or edema. Peripheral pulses within normal limits.,NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits.,SKIN: Noted to be normal. No subcutaneous masses noted.,LYMPH SYSTEM: No lymphadenopathy noted.,BACK: He has pain in his back in general.,ASSESSMENT/PLAN:,1. Diabetes and hypertension, both under less than appropriate control. In fact, we discussed increasing the Lantus. He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control. He knows what needs to be done with the absence of carbohydrates, and especially simple sugar. He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile. I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range. He has allergic rhinitis for which Zyrtec can be used.,2. He has irritable bowel syndrome. We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened. For the bleeding I would like to obtain a sigmoidoscopy. It is bright red blood.,3. For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene. I will look forward to seeing him back in a month. I will call him with the results of his lab. His medications were made out. We will use some Elocon cream for his seborrheic dermatitis of the face. Zyrtec and Flonase for his allergic rhinitis.
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PROCEDURES:,1. Placement of SynchroMed infusion pump.,2. Tunneling of SynchroMed infusion pump catheter,3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position. The patient was prepped and draped in a sterile manner. The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter. This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle. A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle. The needle was withdrawn. The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak. The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure. The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene. Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created. Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery. A pocket was created that would encompass the SynchroMed fusion pump. A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device. The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision. The intrathecal catheter was trimmed. A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together. The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties. Good CSF was then demonstrated flowing through the SynchroMed pump catheter. The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie. Excess catheter was coiled and placed behind the pump. The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall. The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed. The subcutaneous tissues were irrigated with normal saline. The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl. The skin of both wounds was closed with staples. Antibiotic ointment and a sterile dressing were applied. The patient was awake and taken to the recovery room. The patient tolerated the procedure well and was stable at the completion of the procedure. All sponge and lap, needle and instrument counts were correct at the completion of the procedure.pain management, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision,
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{
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"dataset_name": "medical-transcription-4",
"id": 1834
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EXAM: , CT stone protocol.,REASON FOR EXAM:, History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally. These are unchanged. There is no hydronephrosis or significant ureteral dilatation. There is no stone along the expected course of the ureters or within the bladder. There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith. There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal. There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.nephrology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,
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{
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"dataset_name": "medical-transcription-4",
"id": 1835
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SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass. Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma. ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15. Cranial nerves II to XII are grossly intact. Motor exam demonstrates 5/5 strength in all four extremities. Sensation is intact to light touch, pain, temperature, and proprioception. Cerebellar exam is intact. Gait is normal and tandem on heels and toes. Speech is appropriate. Judgment is intact. Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass. Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme. We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing. Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma. The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor. He agrees that he will be n.p.o. after mid night on Wednesday night. He is sent for preoperative assessment with the Anesthesiology tomorrow morning. He has undergone vocational rehab assessment.neurology, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE
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{
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"dataset_name": "medical-transcription-4",
"id": 1836
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SUBJECTIVE:, The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. Normal voiding and stooling pattern. No concerns with hearing or vision. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Allergies: None. Medications: Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:, Unchanged since last checkup.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:, Weight 24 pounds 1 ounce. Height 30 inches. Head circumference 46.5 cm. Temperature afebrile.,General: A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT: Atraumatic, normocephalic. Anterior fontanel is closed. Pupils equally round and reactive. Sclerae are clear. Red reflex present bilaterally. Extraocular muscles intact. TMs are clear bilaterally. Oropharynx: Mucous membranes are moist and pink. Good dentition. Drooling and chewing with teething behavior today. Neck is supple. No lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze. No crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No mass. No organomegaly.,Genitourinary: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength. Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1. Well 1-year-old white female.,2. Anticipatory guidance. Reviewed growth, diet development and safety issues as well as immunizations. Will receive Pediarix and HIB today. Discussed risks and benefits as well as possible side effects and symptomatic treatment. Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available. Gave 1-year well child checkup handout to Mom and Dad.,3. Follow up for the 15-month well child check or as needed for acute care.pediatrics - neonatal, well child check, denver ii, child check, checkup, check, child,
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{
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"dataset_name": "medical-transcription-4",
"id": 1837
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CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.radiology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture,
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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1838
}
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PAST MEDICAL HISTORY: ,She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married. She is an office manager for a gravel company. Her spouse is also overweight. She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time. She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:, Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:, She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass. ABC will be asking for a letter of medical necessity from XYZ. She will also need an EKG and clearance for surgery. She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.bariatrics, elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1839
}
|
CHIEF COMPLAINT:, Fever.,HISTORY OF PRESENT ILLNESS:, This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. Mother states he just completed Amoxil several days ago for a sinus infection. Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum. Mother states that his temperature usually elevates at night. Two days his temperature was 102.6. Mother has not taken it since, and in fact she states today he seems much better. He is cutting an eye tooth that causes him to be drooling and sometimes fussy. He has had no vomiting or diarrhea. There has been no coughing. Nose secretions are usually discolored in the morning, but clear throughout the rest of the day. Appetite is fine.,PHYSICAL EXAMINATION:,General: He is alert in no distress.,Vital Signs: Afebrile.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares patent. Clear secretions present. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular, no murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,Skin: Normal turgor.,ASSESSMENT:,1. Allergic rhinitis.,2. Fever history.,3. Sinusitis resolved.,4. Teething.,PLAN:, Mother has been advised to continue Zyrtec as directed daily. Supportive care as needed. Reassurance given and he is to return to the office as scheduled.consult - history and phy., sinusitis, fever, intermittent fever, allergic rhinitis, fever history, teething,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1840
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CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:, Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected. Free fluid is seen within the right upper quadrant within the lower pelvis. A markedly thickened loop of distal small bowel is seen. This segment measures at least 10-cm long. No definite pneumatosis is appreciated. No free air is apparent at this time. Inflammatory changes around this loop of bowel. Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident. No complete obstruction is suspected, as there is contrast material within the colon. Postsurgical changes compatible with the partial colectomy are noted. Postsurgical changes of the anterior abdominal wall are seen. Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1. Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis. An inflammatory process such as infection or ischemia must be considered. Close interval followup is necessary.,2. Thickening of the urinary bladder wall is nonspecific and may be due to under distention. However, evaluation for cystitis is advised.nephrology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1841
}
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PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION: ,This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty. Markers were applied to both upper lids in symmetrical fashion. The skin was excised from the right upper lid first followed by appropriate muscle resection. Minimal fat removed from the medial upper portion of the eyelid. Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. Attention was then turned to the lower lid. A classic skin muscle flap was created accordingly. Fat was resected from the middle, medial, and lateral quadrant. The fat was allowed to open drain the arcus marginalis for appropriate contour. Hemostasis was controlled with the pinpoint cautery accordingly. Skin was redraped with a conservative amount resected. Running closure with 7-0 nylon was accomplished without difficulty. The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.,Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well.surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1842
}
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CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.radiology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1843
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|
REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use. The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago. The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over. The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago. The patient says he was depressed and agitated. He says he used cocaine by snorting and nitrous oxide but denies other drug usage. He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital. The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure. The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:, Substance abuse as per HPI. The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:, Seizures.,PAST SURGICAL HISTORY:, Shoulder injury.,SOCIAL HISTORY:, The patient lives alone in an apartment uses prior to sobriety 15 months ago. He was a binge drinker, although unable to provide detail about frequency of binges. The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:, None reported.,MEDICATIONS OUTPATIENT:, Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1. Gabapentin 300 mg q.8h.,2. Seroquel 100 mg p.o. q.h.s.,3. Seroquel 25 mg p.o. q.8h. p.r.n.,4. Phenergan 12.5 mg IV q.4h. p.r.n.,5. Acetaminophen 650 mg q.4h. p.r.n.,6. Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown. The patient shows psychomotor agitation and is somewhat irritable. The patient makes fair eye contact and is cooperative. He had answers my questions with "I do not know." Mood "depressed" and "agitated." Affect is irritable. Thought process logical and goal directed with thought content. He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. Insight and judgment are both fair. The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge. The patient is A&O x3.,ASSESSMENT:,AXIS I: Substance withdrawal, substance abuse, and substance dependence.,AXIS II: Deferred.,AXIS III: History of seizures.,AXIS IV: Lives alone and unemployed.,AXIS V: 55.,IMPRESSION:, The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety. The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1. Gabapentin 300 mg q.8h. for agitation and history of seizures.,2. Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult. Please call with further questions.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1844
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PRE-ECLAMPSIA, is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised. It usually occurs from the 20th week of pregnancy to 7 days postpartum. The cause is unknown. It is also known as pregnancy-induced hypertension or toxemia of pregnancy.,ECLAMPSIA, is the end-stage of the pre-eclampsia process. The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years. There are identifiable risk factors for developing pre-eclampsia: family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy). A chronic high blood pressure and underlying blood vessel disease increases the risk. Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage. Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.,SIGNS AND SYMPTOMS:,MILD PRE-ECLAMPSIA:,* Significant blood pressure increase even if you are still within the normal blood pressure limits.,* Swelling in the face, hands and feet which worsens in the a.m.,* Gaining more than a pound a week, especially in the last trimester.,* Routine prenatal checkup reveals protein in the urine.,* Seizures are possible.,SEVERE PRE-ECLAMPSIA:,* More blood pressure increase.,* Further swelling in face, hands and feet.,* Visual disturbances.,* Headache.,* Irritability.,* Abdominal pain.,* Tiredness.,* Decreased urination.,* Seizures possible.,* Nausea and vomiting.,ECLAMPSIA:,* Symptoms worsen.,* Seizures.,* Muscle twitches.,* Coma.,TREATMENT:,* Diagnosis - blood tests, urinalysis, blood pressure monitoring.,* Mild preeclampsia can be treated at home. Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.,* Daily weighing.,* Daily monitoring for protein in urine.,* Medications to lower blood pressure if preeclampsia is severe.,* Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.,* Get lots of rest! Lay on your left side to help circulation.,* Follow any dietary advice given by your doctor.,* Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.,* Never take any medications that are not prescribed or recommended by your physician.,* Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.,RESTRICTING CAFFEINE:,You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda. In addition, you should avoid chocolate that also contains caffeine.,RESTRICTING SALT:,You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration. For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1845
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REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was transferred here. He has been seen by Hospitalists Service. He has not had a recurrent seizure. Electroencephalogram shows slowing. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. There is inhomogeneous uptake consistent with potential necrosis. He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm. The patient was diagnosed with a brain tumor in 1999. All details are still not available to us. He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic. That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone. He tolerated that reasonably well. His wife says it's been several years since he had a scan. His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion. I believe he's had heart disease. Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:, He is living with his wife, next door to one of his children. He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues. Ongoing heart problems, without complaints. No weakness, numbness or tingling, except that related to his chronic neck pain. No history of endocrine problems. He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76. Normal conjunctivae. Ears, nose, throat normal. Neck is supple. Chest clear. Heart tones normal. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. No adenopathy in the neck, supraclavicular or axillary regions. Neurologically alert. Cranial nerves are intact. Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted. Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:, Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings. Dr. X's note suggests discussing the situation in the tumor board on Wednesday. He is stable enough. The pause in his care would not jeopardize his current status. It would be helpful to get old films and pathology from Abbott Northwestern. However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis. Optimizing his treatment would probably be helped by knowing his current grade of tumor.hematology - oncology, spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1846
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HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status.nan
|
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"dataset_name": "medical-transcription-4",
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PREOPERATIVE DIAGNOSES:, Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION: ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: ,Minimal.,FLUIDS:, Crystalloid.,BRIEF HISTORY: ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected. He has received BCG. The patient is doing well. The patient was supposed to come to the OR for surveillance biopsy and pyelograms. The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc. Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed. The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn. The sac was turned upside down and sutures were placed. Careful attention was made to ensure that the cord was open. The testicle was in normal orientation throughout the entire procedure. The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion. Orchiopexy was done at 3 different locations. Hemostasis was obtained using electrocautery. The sac was closed using 4-0 Vicryl. The sac was turned upside down so that when it heals, the fluid would not recollect. The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied. Incision measured about 2 cm in size. Subsequently using ACMI cystoscope, a cystoscopy was performed. The urethra appeared normal. There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder. There was a short prostatic fossa. The bladder appeared normal. There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance. There were no papillary tumors or stones inside the bladder. Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal. A cold cup biopsy of the bladder was done and was fulgurated for hemostasis. The patient tolerated the procedure well. The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy. No heavy lifting, pushing, or pulling. Plan was to follow up in about 2 months.surgery, hydrocele, fulguration, bladder biopsy, hydrocelectomy, cystopyelogram, cystopyelogram bladder, bladder cancer, bladder,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1848
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PREOPERATIVE DIAGNOSIS:, Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: ,The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin over sacral hiatus. A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood. A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level. After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected. The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected. Needle and catheter were removed intact. The patient was discharged in stable condition.pain management, epidural catheter, epidural steroid injection, lumbar disk, steroid injection, fluoroscopy, herniated, lumbar, needle, steroid, epidural, catheter, injection
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1849
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TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:, Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,HEMOSTASIS:, Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES: ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site. The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg. The right ankle tourniquet was then inflated. The right foot was prepped, scrubbed, and draped in normal sterile technique. Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe. The incision was deepened through the subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal. Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered. Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions. Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe. Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present. The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal. The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal. The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation. The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination. The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System. The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy. The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System. The 2 screws were inserted using AO technique. Upon insertion of the screws, the two wires were removed. Fixation of the osteotomy on the table was found to be excellent. The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction. The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation. The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues. Steri-Strips were used to approximate and reinforce the skin edges. At this time, the right ankle tourniquet was deflated. Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff. The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels. The patient was given instructions and education on how to continue caring for her right foot surgery at home. The patient was also given pain medication instructions on how to control her postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.orthopedic, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1850
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S:, The patient is here today with his mom for several complaints. Number one, he has been having issues with his right shoulder. Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. He has been having issues ever since. He is having difficulties raising his arm over his head. He does have some intermittent numbness in his fingers at night. He is not taking any anti-inflammatories or pain relievers. He is also complaining of a sore throat. He did have some exposure to Strep and he has a long history of strep throat. Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. He is also being seen for ADHD by Dr. B. Adderall and Zoloft. He takes these once a day. He does notice when he does not take his medication. He is doing well in school. He is socializing well. He is maintaining his weight and tolerating the medications. However, he is having issues with anger control. He realizes when he has anger outbursts that it is a problem. His mom is concerned. He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:, Reviewed and unchanged.,O:, VSS. In general, patient is A&Ox3. NAD. Heart: RRR. Lungs: CTA. HEENT: Unremarkable. He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip. Musculoskeletal: Limited in range of motion, active on the right. He stops at about 95 degrees. No muscle weakness. Neurovascularly intact. Negative biceps tenderness. Psych: No suicidal, homicidal ideations. Answering questions appropriately. No hallucinations.general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
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PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:, Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:, General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding. Digital exam reveals bright red blood on the finger. He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before. In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa. There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture. No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position. After adequate general anesthesia was induced, the patient was then placed in modified prone position. His buttocks were taped, prepped and draped in a sterile fashion. The anterior rectal wall was exposed using a Parks anal retractor. The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery. There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well. This was controlled with a 3-0 Monocryl figure-of-eight suture. At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.surgery, diarrhea, anterior base lesion, polypoid lesion, transanal excision, transanal, anesthesia, bleeding,
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{
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CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.nan
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{
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IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr. Circumstances leading to this admission: In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h. Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper. ABCD is also complaining of headaches when he takes the medication. Mother reports that on the weekends he is off the medication. She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, "It's an accident." She sees him as impulsive on the weekends, but is not sure if this just isn't "all boy.",Mother reports ABCD has been on medication since kindergarten. Currently, the teachers say he is able to pay attention and he is well behaved in school. Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct. He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep: As stated before, he is having much difficulty on a consistent basis falling asleep. It is 12:00 to 1:00 a.m. before he falls to sleep. When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty. On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite: He will eat breakfast and supper, but not much lunch, if any at all. He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control: Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior. The only exception to this is he gets in occasional fights with his sisters. ABCD denies visual or auditory hallucinations or racing thoughts. He reports his thoughts are sometimes bad because he says sometimes he thinks of the "S" word.,Energy: Mother reports a lot of energy.,Pain: ABCD denies any pain in his body.,Suicidal or homicidal thoughts: He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06. He has received outpatient therapy from XYZ, LCSW. He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar. She reports she has significant moodiness episodes and believes in the past she has had a manic episode. She is currently not on medication. She does not know of anyone else in her family, with the exception of she said her father's behavior was "weird." Biological father's side of the family, mother reports father was very impulsive. He had anger issues. He had drug and alcohol issues. He was in jail for three years for risky behavior. There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years. They divorced when ABCD was 2-1/2 years of age. Currently, father has been deported back to Mexico. He last saw ABCD in March 2006 for one day when they went down to AAAA. He does call on special holidays and his birthday. Contact is brief, but so far has been consistent. Mother is currently seeing R, a significant other, and has been seeing him for the last seven months. ABCD had a good relationship with R. ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as "all wisdom.",PREGNANCY:, Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero. She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:, Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:, Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:, Mother reports ABCD was a very cuddly infant and could sleep well. As a toddler, he was all over the place, climbing and always busy. Elementary school: In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen. ABCD has no history of fire setting or abuse to animals. He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:, Noncontributory.,MEDICAL STATUS AND HISTORY:, ABCD has no known drug allergies. He has no history of heart murmur, heart defect of other heart problems. No history of asthma, seizures or head injuries. He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:, When I asked ABCD whether he likes school, he stated, "No." His grades are okay, per mother. He does have an IEP for the ADHD, but she does not believe he has a learning disability. Behavior problems: He currently is not having any behavior problems in the school. He reports he does not get along with his teachers because they tell him what to do. Strengths: He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:, He reports he has best friends. He named two, D and B, and he does have a friend that is a girl named Kim. When asked if church or God were important to him, he stated, "God is." He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:, In the home, he has chores of taking out the trash.,LEGAL:, He has not been involved in the legal system.,SUPPORT SYSTEMS:, When asked if he feels safe in his home, he stated, "Yes." When asked who he talks to if he is hurt or upset, he stated, "Mom." (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:, He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:, This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions. ABCD kept himself occupied throughout and was very well behaved throughout the session. He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes. Distractibility and attention: He, at times, was very mildly distracted, but otherwise did not appear hyperactive. His judgment was adequate. When asked what he would do if there was a fire in his house, he said, "Get out!" Insight was poor to adequate. Fund of information was good. When asked who the president was, he said, "George Washington." Intelligence is probably average to above average. Speech was normal. He had some difficulty with abstract thinking. He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle. On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly. When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly. Appearance was casual. Hygiene was good. Attitude was cooperative. Speech was normal. Psychomotor was between normal and slightly hyperactive. Orientation was x2. Attention/concentration was intact. Memory was intact at times and then had some memory recall problems with three words. Mood was euthymic. Affect was bright. He has no suicidal or homicidal/violence risks. Perceptions were normal. Thought process logical. Thought content normal. Disassociation none. Sleep: He is having some insomnia. Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:, He has a strong support system in his mother, grandmother, and mother's significant other, Richard. He has good health. He has shown gain from past treatment. He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.nan
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{
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"id": 1854
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PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:, Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:, The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery. The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth. After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1. Methadone.,2. Beta-blocker.,3. Xanax.,4. Norco.,5. Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present. The patient was prepped and draped in sterile fashion. Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible. Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered. Extraction sites were thoroughly curettaged and irrigated. Bony undercuts were removed then smoothed with rongeurs and bone saw. After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures. Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions. Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged. Wound was closed in continuous fashion 3-0 chromic. After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control. Total of 8 mL were used. Throat pack was subsequently removed. Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery. The patient would be placed in 23-hour observation.nan
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{
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"id": 1855
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HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.consult - history and phy., colon cancer screening, loose stools, colorectal, colonoscopy,
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{
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HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above. She has seasonal allergies.,CURRENT MEDICATIONS:, Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.,GENERAL: Her general physical examination was unremarkable.,CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal.,GI: Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal.,CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength.,MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal.,SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities.,GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them.,3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage.,4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system.nan
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"dataset_name": "medical-transcription-4",
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POSTOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy.,OPERATION PERFORMED: Adenotonsillectomy.,ANESTHESIA: General endotracheal.,INDICATIONS: The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE: The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion. A McIvor mouth gag was applied. The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand. A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly. The adenoids were removed with suction electrocautery under mere visualization. The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion. The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion. The inferior, middle and superior pole vessels were further cauterized with suction electrocautery. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.ent - otolaryngology, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
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{
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"dataset_name": "medical-transcription-4",
"id": 1858
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PREOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,POSTOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,TITLE OF PROCEDURES: ,1. Perlane injection for the nasolabial fold.,2. Restylane injection for the glabellar fold.,ANESTHESIA: ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. This includes risk of bleeding, infection, scarring, need for further procedure, etc. The patient did sign the informed consent form regarding the Perlane and Restylane. She is aware of the potential risk of bruising. The patient has had Cosmederm in the past and had had a minimal response with this. Please note Lasercaine had to be applied 30 minutes prior to the procedure. The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold. We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold. They were carefully massaged into good position at the end of the procedure. She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site. She has a resting line of the mid glabella that did not respond with previous Botox injection. Once this was filled, the Restylane was massaged into the proper tissue plane. Cold compressors were applied afterwards. She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time. Post Restylane and Perlane precautions have been reviewed with the patient as well.surgery, lasercaine, nasolabial mesiolabial fold, mid glabellar fold, perlane injection, restylane injection, nasolabial fold, mesiolabial fold, glabellar fold, injection, perlane, nasolabial, glabellar, restylane
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{
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"dataset_name": "medical-transcription-4",
"id": 1859
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ADMITTING DIAGNOSIS:, Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1. Aftercare following surgery for injury and trauma.,2. Decubitus ulcer, lower back.,3. Alcohol induced persisting dementia.,4. Anemia.,5. Hypokalemia.,6. Aftercare healing traumatic fracture of the lower arm.,7. Alcohol abuse, not otherwise specified.,8. Aftercare healing traumatic lower leg fracture.,9. Open wound of the scalp.,10. Cervical disk displacement with myelopathy.,11. Episodic mood disorder.,12. Anxiety disorder.,13. Nervousness.,14. Psychosis.,15. Generalized pain.,16. Insomnia.,17. Pain in joint pelvic region/thigh.,18. Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:, None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE: ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident. He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury. When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm. He had a brace placed in the left leg for his left tibial plateau fracture. He was confused initially and initially started on rehab. He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. He did well from orthopedic standpoint. He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. He made slow progress from therapy. His confusion gradually cleared. He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this. He did require some Ativan for agitation. He was on chronic pain medications as an outpatient. His medications were adjusted here and he did well with this as well. The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. We did have orthopedic followup. He was taken out of his right leg brace the week of 06/16/2008. He did well with therapy. Overall, he was doing much and much better. He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better. He was using a wheeled walker. He was able to bear weight on his left leg. His pain level had been well controlled and his moods had improved dramatically. He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1. Calcium with vitamin D 1 tablet twice a day.,2. Ferrous sulfate 325 mg t.i.d.,3. Multivitamin 1 daily.,4. He was on nicotine patch 21 mg per 24 hour.,5. He was on Seroquel 25 mg at bedtime.,6. He was on Xenaderm for his sacral pressure ulcer.,7. He was on Vicodin p.r.n. for pain.,8. Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.nan
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{
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"dataset_name": "medical-transcription-4",
"id": 1860
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PREOPERATIVE DIAGNOSIS: ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum. Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses. There is a hernia on the left side. The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table. General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically. A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision. An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia. External ring was exposed with dissection as well. The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal. The testes were freed with dissection by removing cremasteric and spermatic fascia. The hernia sac was separated from the cord, twisted and suture ligated at the internal ring. Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring. However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided. This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel. The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures. The skin was approximated with interrupted #5-0 chromic catgut sutures. Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good. Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture. Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion. However, on this side, there was no inguinal hernia. The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side. The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure. Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision. The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition. Instrument and sponge counts were correct. There were no apparent complications. Estimated blood loss was less than 20 to 30 mL.surgery, bilateral orchiopexy, bilateral undescended testes, prentiss maneuver, subcutaneous tissues, internal ring, dartos pouch, scrotal incisions, undescended testes, spermatic cord, inguinal canal, testes, inguinally, orchiopexy, undescended, cord, vicryl, ultrasound, spermatic, canal,
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{
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"dataset_name": "medical-transcription-4",
"id": 1861
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She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control. Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:, Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:, Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds. On general exam she has an area of tenderness on palpation in the left parietal region of her scalp. Neurological exam is detailed on our H&P form. Her neurological exam is within normal limits.,IMPRESSION AND PLAN:, For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy. If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica. We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.general medicine, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran
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{
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"dataset_name": "medical-transcription-4",
"id": 1862
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EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.orthopedic, three views, radiopaque, fractures, foot trauma
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1863
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PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.gastroenterology, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology
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{
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"dataset_name": "medical-transcription-4",
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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.soap / chart / progress notes, 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_name": "medical-transcription-4",
"id": 1865
}
|
PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute cholecystitis.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS: , None.,PROCEDURE: ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia. An open pneumoperitoneum was created with Hasson technique. Three additional ports were placed in the usual fashion. The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas. It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips. The gallbladder was then taken down from the gallbladder fossa with electrocautery. There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie. The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones. The fascia had to be opened. The gallbladder had to be opened, and the stones had to be extracted carefully. When it was completed, I went back to the abdomen and achieved complete hemostasis. The ports were then removed under direct vision with the scope. The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl. All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.surgery, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1866
}
|
PREOPERATIVE DIAGNOSIS:, Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:, Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:, This patient has been experiencing difficulty with eyesight regarding activities of daily living. There has been a progressive and gradual decline in the visual acuity. The cataract was believed related to her decline in vision. The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail. The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery. The possibility of needing intraocular lens exchange or incorrect lens power was discussed. Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed. It was explained that some or all of these complications might arise at the time of or months to years after surgery. The patient had a good understanding of the risks with the proposed, elective eye surgery. The patient accepted these risks and elected to proceed with cataract surgery. All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. The pupil was dilated per protocol. The patient was taken to the operating room and placed in the supine position. After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage. No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion. An eyelid speculum was used to separate the eyelids. A crescent blade was used to make a clear corneal temporally located incision. A 1-mm Dual-Bevel blade was used to make a paracentesis site. The anterior chamber was filled with viscoelastic (Viscoat). The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision. A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision. A 25-gauge pre-bent cystotome used to begin a capsulorrhexis. The capsulorrhexis was completed with the Utrata forceps. A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted. The lens was able to be freely rotated within the capsular bag. Divide-and-conquer ultrasound was used for phacoemulsification. After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment. Each of the four nuclear quadrants was phacoemulsified. Aspiration was used to remove all remaining cortex. Viscoelastic was used to re-inflate the capsular bag. An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag. The trailing haptic was placed with the Sinskey hook. The lens was made well centered and stable. Viscoelastic was aspirated. BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure. A Weck-Cel sponge was used to check both incision sites for leaks and none were identified. The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens. The eyelid speculum was removed and the patient was cleaned free of Betadine. Vigamox and Econopred drops were applied. A soft eye patch followed by a firm eye shield was taped over the operative eye. The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed. All questions were answered. The discharge instructions were also reviewed with the patient by the discharging nurse. The patient was comfortable and was discharged with followup in 24 hours. Complications none.ophthalmology, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1867
}
|
PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:, Cauterization of peri and intra-anal condylomas.,ANESTHESIA: ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week.surgery, intra-anal, perianal, acuminata, cauterization, condyloma, anal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1868
}
|
PREOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.,INDICATIONS FOR THE PROCEDURE: , This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma. The patient has a history of lymphoma and is in remission. An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma. A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung. PET scan was, otherwise, negative for spread and resection was advised. All the risk and benefits were fully explained to the patient and she elected to proceed as planned. She was transferred to rehab for couple of weeks to buildup strength before the surgery.,PROCEDURE IN DETAIL:, In the operating room under anesthesia, she was prepped and draped suitably. Dr. B was the staff anesthesiologist. Left muscle sparing mini thoracotomy was made. The serratus and latissimus muscles were not cut but moved out to the way. Access to the chest was obtained through the fifth intercostal space. Two Tuffier retractors of right angles provided adequate exposure.,The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology. The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.,The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk. The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun. Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun. Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.,The specimen was delivered and sent to pathology. The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe. Frozen section showed that the margin was negative.,The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak. A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together. A #2 Vicryl pericostal sutures were now applied. The serratus and latissimus muscles retracted back in place. A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin. The patient was transferred to the ICU in a stable condition.cardiovascular / pulmonary, upper lobe, intercostal nerve block, non-small-cell carcinoma, axillary lymph node, endo-gia, latissimus, lobectomy, lymph node dissection, lymphoma, pulmonary vein, serratus, thoracotomy, muscle sparing mini thoracotomy, upper lobectomy, staple gun, intercostal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1869
}
|
HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.neurology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1870
}
|
PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES: ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA: ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin. The patient had buried penis with significant obesity issues in the suprapubic area. Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed. The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix. Consent had been obtained. Risk of scarring, decrease in penile sensation, and unexpected complications were discussed. The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc. Consent was obtained.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in usual sterile fashion. Local MAC anesthesia was applied. After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block. The patient had significant phimosis and slight ventral chordee. Using marking pen, the excess foreskin was marked off. Using a knife, the ventral chordee was released. The urethra was intact. The excess foreskin was removed. Hemostasis was obtained using electrocautery. A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done. The patient tolerated the procedure well. There was excellent hemostasis. The penis was straight. Vaseline gauze and Kerlix were applied. The patient was brought to the recovery in stable condition. Plan was for removal of the dressing tomorrow. Okay to shower after 48 hours.urology, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1871
}
|
CHIEF REASON FOR CONSULTATION:, Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:, This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. Patient does not get any chest pain or choking in the neck or pain in the back. Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:, Patient does not take any specific medications.,PAST HISTORY:, The patient underwent hysterectomy in 1986.,FAMILY HISTORY:, The patient is married, has four children who are doing fine. Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1872
}
|
PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table. After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner. Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw. Pericardial and thymus fat pad was divided. The left internal mammary artery was harvested and spatulated for anastomosis. Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips. The thigh was closed multilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors. After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. Medtronic retractors used to expose the circumflex. Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique. The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique. Deairing procedure was carried out. The bulldogs were removed. The patient maintained good normal sinus rhythm with good mean perfusion. The patient was weaned from cardiopulmonary bypass. The arterial and venous lines were removed and doubly secured. Protamine was delivered. Meticulous hemostasis was present. Platelets were given for coagulopathy. Chest tube was placed and meticulous hemostasis was present. The anatomy and the flow in the grafts was excellent. Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique. The skin was closed with subcuticular 4-0 Dexon suture technique. The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.cardiovascular / pulmonary, coronary artery disease, angina, coronary artery bypass grafting, internal mammary artery, coronary artery, vein graft, artery, bivad, cabg, medtronic, anastomosis, mammary, vein, circumflex,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1873
}
|
PREOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1. Left midface elevation with nasolabial fold elevation.,2. Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service. The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity. In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry. The patient was seen in consultation and felt to be a surgical candidate for improvement. Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication. The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table. Dose of antibiotics was given to the patient. Compression devices were placed on the lower extremities to prevent the knee embolic events. The patient was turned to 180 degrees. The ETT tube was secured and the area was then prepped and draped in usual sterile fashion. A head wrap was then placed on the position and we then began our local. Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access. Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves. This was done bilaterally. We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue. We continued down to the lateral orbital rim until we identified periosteum. We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially. Care was taken to preserve the infraorbital nerve and that was visualized after elevation. We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw. After this was then carried out, we then clipped and cut as well as the end of the screw. Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl. Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry. Excess skin along the incision was then removed as well the skin from just lateral to the canthus. Care was taken to leave the orbicularis muscle down. We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case. A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour. This was carried out using a 15 blade down to subcutaneous tissue. The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture. At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally. As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision. We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only. This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease. Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements. Dr. Y was available and participated in the portions of the case as well.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1874
}
|
HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.neurology, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1875
}
|
MULTISYSTEM EXAM,CONSTITUTIONAL: ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: ,The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: ,The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: ,The neck was supple. The thyroid gland was not enlarged by palpation.,RESPIRATORY: ,The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.,GU: , The scrotal elements were normal. The testes were without discrete mass. The penis showed no lesion, no discharge.,LYMPHATIC: ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL: ,The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.,NEUROLOGIC: ,Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.consult - history and phy., within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1876
}
|
EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing.consult - history and phy., erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: 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": 1877
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PROCEDURE: , Thoracic epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 7 cc preservative free normal saline and 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was discharged to recovery room in stable condition.pain management, loss of resistance, cerebrospinal fluid, thoracic epidural steroid injection, fluoroscopy, thoracic, steroid, epidural, injection,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1878
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PREOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,OPERATION PERFORMED:, Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place. The skin was prepped and draped in a sterile classical fashion. The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter. The patient was given oxygen, intravenous sedation and analgesics as needed. The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's "Scottie dog" and the opening of the facet.,After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets. A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique. After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule. After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet. The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1879
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SUBJECTIVE:, The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. She follows with Dr. XYZ on her hypertension, as well as myself. She continues to gain weight. Diabetes is therefore a major concern. In fact, her dad had diabetes and she has a brother who has diabetes. The patient also has several additional concerns she brings up today. One is that her left knee continues to bother her and it hurts. She cannot really isolate where the pain is, it just seems to hurt through her knee. She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999. There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially. She would like to have this x-rayed again today. She is certainly not interested in any surgery. She has noted that it particularly hurts to kneel. In addition, she complains of her stools being a baby-yellow. She has rectal bleeding off and on. It is bright red. She had a colonoscopy done in 1999. She does have a family history of colon cancer questionable in her mother, who is deceased. She complains of some diffuse abdominal pain off and on. She has given up fast foods and her pop and this has not seemed to help. She does admit however, that she is not eating right. Sometimes her stools are hard. Sometimes they are runny. The blood does not really seem to be related to necessarily a hard stool. It is always bright red and will sometimes drip into the toilet. Over the last couple of days, she had also been sneezing and has had an itchy throat. She tried some Claritin and this did not help. She has had some body aches. She is finally feeling better today with this. She also is questioning whether she has some sleep apnea. She will awaken suddenly in the middle of the night. She was told that she does snore. She does not smoke. As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy.,PREVENTATIVE HISTORY:, She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:, Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:, Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:, Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General: Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals: Her weight today is 246 pounds. In March of 2002 she weighed 231 pounds. In March 2001 she weighed 203 pounds. Her blood pressure is 160/78. Pulse is 84. Respiratory rate of 20. She is afebrile.,HEENT: Head is of normocephalic, atraumatic. PERLA. Conjunctivae clear. TMs are unremarkable and canals are patent. Nasal mucosa is slightly reddened. Nares are patent. Throat shows some clear posterior pharyngeal drainage. Throat is slightly reddened. Non-exudative. No oral lesions or dental caries noted.,Neck: Supple, No adenopathy. Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart: Regular rate and rhythm without murmurs, clicks or rubs. PMI is nondisplaced.,Lungs: Clear to A&P. No CVA tenderness.,Breast exam: Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge. Breasts were examined both lying and sitting.,Abdomen: Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses. Non tender.,Pelvic exam: BUS unremarkable. Speculum exam shows normal physiologic discharge. There are some atrophic vaginal changes. Cervix visualized, no gross abnormalities. Pap smear obtained. Bimanual is negative for any adnexal masses or tenderness. Rectal exam is negative for any adnexal masses or tenderness. No rectal masses. She does have some external hemorrhoids, none of which are inflamed at this time. No palpable rectal masses.,Neuromusculoskeletal exam: Cranial nerves II-XII are grossly intact. No cerebellar signs are noted. No evidence of a gait disturbance. DTRs are 1+/4+ and equal throughout. Good uptoeing. Skin: Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1. Weight-gain.,2. Hypertension.,3. Lipometabolism disorder.,4. Rectal bleeding.,5. Left knee pain.,6. Question of sleep apnea.,7. Upper respiratory infection, improving.,8. Gynecological examination is unremarkable for her age.,PLAN:, We discussed at length, the issue of sleep apnea and its negative sequela. I have recommended that she be referred for a sleep study. She is certainly at risk for sleep apnea. She refuses this. I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better. I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable. I reviewed this with her. I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them. I will dictate Dr. XYZ a note. I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort. She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her. This however, has been some time ago. I suspect she has an element of irritable bowel syndrome. I have strongly encouraged weight reduction, both through diet and exercise. I would like to see her back in the office in six months. I did retake her blood pressure today and it was 130/70. She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK. I will her mail the results. I have strongly encouraged medication management if her lipids are elevated. I think she is amenable to this. Her DEXA scan is up to date having been done on 04/09/03. I do not recommend one this year.nan
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{
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"dataset_name": "medical-transcription-4",
"id": 1880
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PREOPERATIVE DIAGNOSIS: , Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia indirect.,ANESTHESIA: , Spinal with local.,COMPLICATIONS:, None.,DISPOSITION,: The patient tolerated the procedure well, was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,BRIEF HISTORY: , The patient is a 60-year-old female that presented to Dr. X's office with complaints of a bulge in the left groin. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a left indirect inguinal hernia.,PROCEDURE: , After informed consent was obtained, risks and benefits of the procedure were explained to the patient. The patient was brought to the operating suite. After spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion. In the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% Marcaine. Next, a skin incision was made with a #10 blade scalpel. Using Bovie electrocautery, dissection was carried down to Scarpa's fascia until the external oblique was noted. Along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat. Next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament. Attention was next made to ligating the hernia sac at its base for removal. The hernia sac was opened prior grasping with hemostats. It was a sliding indirect hernia. The bowel contents were returned to abdomen using a #0 Vicryl stick tie pursestring suture at its base. The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen. This was then sutured at the apex of the repair down to the conjoint tendon. Next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 Vicryl suture and removed as specimen. Attention was next made to reapproximate it at floor with a modified ______ repair. Using a #2-0 Ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia. Once this was done, the external oblique was closed over, reapproximated again with a #2-0 Ethibond suture catching each hump in between each repair from the prior floor repair. This was done in simple interrupted fashion as well. Next Scarpa's fascia was reapproximated with #3-0 Vicryl suture. The skin was closed with running subcuticular #4-0 undyed Vicryl suture. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure very well and he was transferred to Recovery in stable condition. The patient had an abnormal chest x-ray in preop and is going for a CT of the chest in Recovery.surgery, bulge, groin, ethibond suture, vicryl suture, external oblique, inguinal hernia, hernia, inguinal, ligament, oblique, vicryl, indirect, sac, suture, repair,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1881
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CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.neurology, cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1882
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CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:, Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:, None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:, He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC: He denies any chest pain or shortness of breath.,GI: As noted above.,GU: As noted above.,ENDOCRINE: He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant 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, S4, or gallop. There is no murmur.,ABDOMEN: Soft. It is nontender. There is no mass or organomegaly.,GU: Unremarkable.,RECTAL: Deferred.,EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:, Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1883
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HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss. At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:, Significant for hypertension, for which the patient takes Norvasc and Lopressor for. She also suffers from high cholesterol and is on lovastatin for this. She has depression, for which she takes citalopram. She also stated that she had a DVT in the past prior to her hysterectomy. She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones. She also had a hysterectomy in 1994 secondary to hemorrhage. The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker. She is married, with 2 children aged 22 and 28. She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY: ,Significant for high blood pressure and diabetes as well as cancer on her father side. He did pass away from congestive heart failure. Mother suffers from high blood pressure, cancer, and diabetes. Her mother has passed away secondary to cancer. She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling. The patient also wears glasses for vision and has dentures. She does complain of shortness of breath with exertion. She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease. She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION: ,The patient is a well-nourished, well-developed female, in no distress. Eye Exam: Pupils equal and reactive to light. Extraocular motions are intact. Neck Exam: No cervical lymphadenopathy. Midline trachea. No carotid bruits. Nonpalpable thyroid. Neuro Exam: Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. Lung Exam: Clear breath sounds without rhonchi or wheezes. Cardiac Exam: Regular rate and rhythm without murmur or bruits. Abdominal Exam: Positive bowel sounds. Soft, nontender, obese, and nondistended abdomen. Lap cholecystectomy scars noted. No obvious hernias. No organomegaly appreciated. Lower extremity Exam: Edema 1+. Dorsalis pedis pulses 2+.,ASSESSMENT: ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy. Also the patient will meet with the dietitian and psychologist as per her usual routine. I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.bariatrics, jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1884
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|
SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477. She gave herself, in smaller increments, a total of 70 extra units of her Humalog. Ten of those units were injectable; the others were in the forms of pump. Her blood sugar was over 600 when she went to the hospital later that day. She is here at this consultation complaining of not feeling well still because she has a cold. She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:, Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper. Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours. A diet history was obtained. I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended. A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended. The Lilly guide for meal planning was provided and reviewed. Additional carbohydrate counting book was provided.,ASSESSMENT:, The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall. It is based on the 500 rule which suggests this ratio. We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents. We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources. She does seem to have a pattern of fixing blood sugars later in the day after they are elevated. We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals. With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner. Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately. The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:, Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed. Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day. This was a one-hour consultation. Provided my name and number should additional needs arise.diets and nutritions, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1885
}
|
CHIEF REASON FOR CONSULTATION:, Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:, This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1. Astelin nasal spray.,2. Evista 60 mg daily.,3. Lopressor 25 mg daily.,4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:, The patient underwent right foot surgery and C-section.,FAMILY HISTORY:, The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks. ,ALLERGIES:, THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:, Otherwise negative. ,PHYSICAL EXAMINATION: , ,GENERAL: Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.,NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.,CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. ,CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.,ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.,EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO: Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1886
}
|
PREOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS: ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital. This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention. He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam. Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum. Minimal cartilaginous pieces were at the patellar tendon. He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department. A thigh high tourniquet was placed. He is prepped and draped in the usual sterile manner. Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes. Straight incision is carried down through skin and subcutaneous tissue anteriorly. Hemostasis was controlled via electrocoagulation. Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape. The inferior pole was freshened up. Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer. This was tied over the bony bridge superiorly. There was excellent reduction of the tendon to the patella. Interrupted running #1-Vicryl suture was utilized for over silk. A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum. There was excellent repair. Copious irrigation was carried out. Tourniquet was dropped and hemostasis controlled via electrocoagulation. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin. Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing. Digits were warm and no brawny pulses present at the end of the case. The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion. He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1887
}
|
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.obstetrics / gynecology, 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": 1888
}
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CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:, None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day.,SOCIAL HISTORY: ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings.,HEART: Regular rate and rhythm, without murmur. Normal S1, S2.,LUNGS: Clear. No rales. No wheeze. Good excursion.,ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES: No edema, clubbing, or cyanosis. No rash.,LABORATORY FINDINGS: , On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1. Hypoglycemia due to not eating her meals on a regular basis.,2. Hypertension.,3. Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1889
}
|
DISCHARGE DIAGNOSIS: ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1. Chronic pain.,2. Tobacco use.,3. History of hepatitis C.,REASON FOR ADMISSION:, The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. He has had prolonged hospitalizations because of this problem. He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg. Examination in the emergency room revealed significant concern for significant cellulitis. Decision was made to admit him to the hospital.,HOSPITAL COURSE:, The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking. The patient had edema of his bilateral lower extremities. The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C. Hospital consult was obtained. This included an ultrasound of his abdomen, which showed just mild cirrhosis. His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well. The patient eventually grew MRSA in a moderate amount. He was treated with IV vancomycin. Local wound care and elevation. The patient had slow progress. He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression. The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days. He was also given prescription for Percocet and OxyContin, picked up at my office. He is instructed to do daily wound care and also wrap his leg with an Ace wrap. Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.general medicine, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1890
}
|
Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:, Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:, The patient denies any past surgical history.,MEDICATIONS:, The patient takes Cardizem CD 240-mg. The patient also takes eye drops.,ALLERGIES:, The patient denies any allergies.,SOCIAL HISTORY:, The patient smokes about a pack a day for more than 25 years. The patient drinks alcohol socially.,FAMILY HISTORY:, Significant for hypertension and strokes.,REVIEW OF SYSTEMS:, The patient does have a good appetite and no weight loss. She does have intermittent rectal bleeding associated with irritation in the rectal area. The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:, This is a 48 year-old lady who is awake, alert and oriented x 3. She does not seem to be in any acute distress. Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. HEENT is normocephalic, atraumatic. Sclerae are non-icteric. Her neck is supple, no bruits, no lymph nodes. Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. The cardiovascular system has a regular rate and rhythm, no murmurs. The abdomen is soft and non-tender. Bowel sounds are positive and no organomegaly. Extremities have no edema.,IMPRESSION:, This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. The patient is chronically constipated.,1. Rule out colon cancer.,2. Rule out colon polyps. ,3. Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:, Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MDnan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1891
}
|
FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.neurology, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1892
}
|
SUBJECTIVE:, A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago. Also, I cleaned out his maxillary sinuses. Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue. The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening. He finished up his Augmentin, by a day or two later he was off the Lortab. Mom has not noticed any unusual voice change. No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce. He has not had any nasal discharge or ever had any bleeding. He seems to be breathing better.,OBJECTIVE:, Exam looks good. The pharynx is well healed. Tongue mobility is normal. Voice sounds clear. Nasal passages reveal no discharge or crusting.,RECOMMENDATION:, I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive. He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth. It is okay to chew gum and it is okay to eat crunchy foods such as potato chips. The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well. There are no other restrictions or limitations. I told Mom, I had written to Dr. XYZ to let her know of the findings. The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed. He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.office notes, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1893
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:, Penicillin.,SOCIAL HISTORY:, He is not a smoker. He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT: Examination unremarkable.,Breasts: Examination deferred.,Chest: Clear to auscultation.,Cardiac: Regular rate and rhythm.,Abdomen: Soft and nontender. He has no hernias.,Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities: Examination unremarkable.,Neurologic: Examination nonfocal.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Erectile dysfunction.,PLAN: ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.consult - history and phy., gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1894
}
|
RIGHT LOWER EXTREMITY:, The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:, The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery. Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease.,radiology, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1895
}
|
HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1896
}
|
HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot. The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1. Diabetes mellitus type 2.,2. Diabetic nephropathy.,3. Chronic kidney disease, stage 4.,4. Hypertension.,5. Hypercholesterolemia and hyperlipidemia.,6. Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:, Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:, NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General: The patient is alert and oriented, in no acute distress.,Vital Signs: Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. The patient's weight is 105.6 kg.,Head: Normocephalic.,Neck: Supple. No JVD. No adenopathy.,Chest: Symmetric. No retractions.,Lungs: Clear.,Heart: RRR with no murmur.,Abdomen: Obese, soft, and nontender. No rebound. No guarding.,Extremity: She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date. The patient's white cell is 12.7, hematocrit 26.1. The patient has 90% segs and 0% bands. Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1. Urinary tract infection.,2. Acute gouty attack.,3. Diabetes mellitus with diabetic nephropathy.,4. Hypertension.,5. Hypercholesterolemia.,6. Peripheral vascular disease, status post recent PTA in the right side.,7. Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment. We will add allopurinol 50 mg daily. This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1897
}
|
OPERATIVE NOTE: ,The patient was taken to the operating room and was placed in the supine position on the operating room table. A general inhalation anesthetic was administered. The patient was prepped and draped in the usual sterile fashion. The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated. Next a midline ventral type incision was made opening the meatus. This was done after clamping the tissue to control bleeding. The meatus was opened for about 3 mm. Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds. Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures. The meatus still calibrated between 10 and 12 French. Antibiotic ointment was applied. The procedure was terminated. The patient was awakened and returned to the recovery room in stable condition.urology, urethral meatus, mosquito hemostat, meatus, mucosal edges, glans, meatotomyNOTE,: 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.,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1898
}
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BNP, (brain natriuretic peptide or B-type natriuretic peptide) is a substance produced in the heart ventricles when there is excessive strain to the heart muscles. A blood test for this can be used as an effective parameter for detecting an acute event of congestive heart failure, where the heart is unable to pump sufficient amount of blood required by the body's needs. When a person has a heart failure (such as MI), BNP is secreted so immensely that it sits well above the measurable range. Values above 100 signal a problematic situation and those above 500 a highly demanding state. Note that a person with a remote history of heart problems may not have BNP levels elevated, but it is used as a measure of acute events.,On the other hand, ,BMP, or basic metabolic panel is not a single test but a group of 8 tests (glucose, calcium, sodium, potassium, bicarbonate, chloride, BUN, creatinine). Any test that has the word panel in it is not a single test, so cannot have a single value.,With this logic in mind, if a doctor uses phrases like "BNP/BMP is elevated/negative/positive/is greater than/less than etc." and then a single value, it may not be BMP. You can also take the hint from the file whether the patient presented to the hospital with an acute coronary event. Likewise, if he says multiple values for this test, this must be BMP.,lab medicine - pathology, brain natriuretic peptide, b-type natriuretic peptide, basic metabolic panel, glucose, calcium, sodium, potassium, bicarbonate, chloride, bun, creatinine, natriuretic peptide, bmp, bnp,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 1899
}
|
The patient underwent an overnight polysomnogram on 09/22/06 and the details of the polysomnographic study are reported separately. The highlights of the study include the following:,A. Obstructive apneas and hypopneas were identified with an overall apnea-hypopnea index of 15.2 events per hour in the supine position. All events occurred in the supine position and were more prominent during stage REM sleep. Minimum oxygen saturation was 88%.,B. Periodic limb movements in sleep were identified with an overall index of 32 events per hour of sleep.,C. The patient's sleep efficiency was reduced to 89.2%. There was significant sleep fragmentation due to the obstructive apneas and hypopneas as well as due to the periodic limb movements in sleep disorder. The patient did not achieve any stage III/IV sleep and stage REM sleep was diminished at 12.7%. There was a corresponding increase in stage I sleep and stage II sleep at 10.8% and 65.7% respectively.,DIAGNOSTIC IMPRESSION:,1. Obstructive sleep apnea syndrome, supine position dependent, moderate (780.53-0).,2. Periodic limb movement in sleep disorder, moderate (780.53-4).,CASE DISCUSSION: , Thank you once again for allowing us to participate in the care of the patient here at the Sleep Clinic.,The patient exhibits obstructive sleep apnea, a condition associated with increased risk of myocardial infarction, stroke and sudden death. Furthermore, patients with this condition are susceptible to excessive daytime sleepiness while driving and there is a higher incidence of automobile accident. The patient should be warned with regards to these possibilities.,Patients with this condition can be successfully treated with nasal CPAP (continuous positive airway pressure), so that the patient should return to the sleep laboratory for repeat overnight polysomnogram with CPAP titration. The sleep laboratory if necessary can introduce the patient to the proper use of the CPAP equipment and to determine a necessary pressure to prevent apneas.,It is reported that the patient undergo careful ENT/maxillofacial evaluation by a physician familiar with sleep disorders. Anatomical abnormalities in the upper airway often cause or predispose to this condition. Surgical intervention may be helpful or necessary if such conditions exist. Alternatively, ________ may be of benefit in some patients depending upon the anatomical abnormalities.,Obstructive sleep apnea is worsened by obesity. The patient should be encouraged to lose weight. Patients usually lose weight more effectively when involved in a behavioral weight loss program. It is sometimes difficult for patients to lose weight until the OSA is adequately treated because excessive daytime sleepiness results in decreased physical activity in the daytime.,Patient may have worsening obstructive sleep apnea by nasal airway obstruction and nasal congestion. If present, these conditions should be treated. In addition, any home allergens such as pets, down bedding or other factors should be removed from the sleep environment.,The patient should be informed that obstructive sleep apnea may be worsened by the use of alcohol or sedative medications particularly taken in the evening. Therefore, the evening use of sedative medications and alcohol are to be avoided.,The patient also exhibits periodic limb movements in sleep disorder. This may require treatment. However, it will be appropriate to obtain the repeat overnight polysomnogram with CPAP titration to see if the PLMS continues to be troublesome. If so, treatment recommendations will be made.sleep medicine, periodic limb movement, cpap, limb movements in sleep, obstructive sleep apnea, overnight polysomnogram, sleep, overnight, polysomnogram, obstructive, apneas,
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