text stringlengths 40 18.4k | label class label 40
classes |
|---|---|
PREOPERATIVE DIAGNOSIS Possible inflammatory bowel disease. POSTOPERATIVE DIAGNOSIS Polyp of the sigmoid colon. PROCEDURE PERFORMED Total colonoscopy with photography and polypectomy. GROSS FINDINGS The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease.... | 38 Surgery |
EXAM CT cervical spine C-spine for trauma. FINDINGS CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. Cervical vertebral body height alignment and interspacing are maintained. There is no evidence of fracture... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Obstructive sleep apnea. POSTOPERATIVE DIAGNOSIS Obstructive sleep apnea. PROCEDURE PERFORMED 1. Tonsillectomy. 2. Uvulopalatopharyngoplasty. ANESTHESIA General endotracheal tube. BLOOD LOSS Approximately 50 cc. INDICATIONS The patient is a 41-year-old gentleman with a history o... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Ruptured distal biceps tendon right elbow. POSTOPERATIVE DIAGNOSIS Ruptured distal biceps tendon right elbow. PROCEDURE PERFORMED Repair of distal biceps tendon right elbow. PROCEDURE The patient was taken to OR Room #2 and administered a general anesthetic. The right upper extre... | 27 Orthopedic |
HISTORY The patient is 14 months old comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get wors... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Right AC separation. POSTOPERATIVE DIAGNOSIS Right AC separation. PROCEDURES Removal of the hardware and revision of right AC separation. ANESTHESIA General. BLOOD LOSS 100 cc. COMPLICATIONS None. FINDINGS Loose hardware with superior translation of the clavicle implants. IMP... | 38 Surgery |
PREPROCEDURE DIAGNOSIS Left leg claudication. POSTPROCEDURE DIAGNOSIS Left leg claudication. OPERATION PERFORMED Aortogram with bilateral segmental lower extremity run off. ANESTHESIA Conscious sedation. INDICATION FOR PROCEDURE The patient presents with lower extremity claudication. She is a 68-year-... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Osteomyelitis right hallux. POSTOPERATIVE DIAGNOSIS Osteomyelitis right hallux. PROCEDURE PERFORMED Amputation distal phalanx and partial proximal phalanx right hallux. ANESTHESIA TIVA/local. HISTORY This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/20... | 31 Podiatry |
PREOPERATIVE DIAGNOSIS Right ureteral calculus. POSTOPERATIVE DIAGNOSIS Right ureteropelvic junction calculus. PROCEDURE PERFORMED 1. Cystourethroscopy. 2. Right retrograde pyelogram. 3. Right double-J stent placement 22 x 4.5 mm. FIRST SECOND ANESTHESIA General. SPECIMEN Urine for culture and sensitivi... | 39 Urology |
SUBJECTIVE The patient is a 60-year-old female who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heart... | 14 Gastroenterology |
HISTORY The patient is a 25-year-old gentleman who was seen in the emergency room at Children s Hospital today. He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had rib cage pain for the last few days. He denies any history of trauma. He does have incr... | 12 Emergency Room Reports |
HISTORY OF PRESENT ILLNESS This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant. The patient did well after the liver transplant and the only problems started 1. History of food allergies. 2. History of den... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS ES 1. Endocarditis. 2. Status post aortic valve replacement with St. Jude mechanical valve. 3. Pericardial tamponade. POSTOPERATIVE DIAGNOSIS ES 1. Endocarditis. 2. Status post aortic valve replacement with St. Jude mechanical valve. 3. Pericardial tamponade. PROCEDURE 1. Emergent subxipho... | 3 Cardiovascular / Pulmonary |
PROCEDURE PERFORMED Right heart catheterization. INDICATION Refractory CHF to maximum medical therapy. PROCEDURE After risks benefits and alternatives of the above-mentioned procedure were explained to the patient and the patient s family in detail informed consent was obtained both verbally and in writing.... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Basal cell carcinoma 0.8 cm diameter right medial canthus. POSTOPERATIVE DIAGNOSIS Basal cell carcinoma 0.8 cm diameter right medial canthus. OPERATION Excision basal cell carcinoma 0.8 cm diameter right medial canthus with frozen section and reconstruction of defect 1.2 cm di... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Left hip degenerative arthritis. POSTOPERATIVE DIAGNOSIS Left hip degenerative arthritis. PROCEDURE PERFORMED Total hip arthroplasty on the left. ANESTHESIA General. BLOOD LOSS 800 cc. The patient was positioned with the left hip exposed on the beanbag. IMPLANT SPECIFICATION A 5... | 27 Orthopedic |
INFORMANT Dad on phone. Transferred from ABCD Memorial Hospital rule out sepsis. HISTORY This is a 3-week-old NSVD Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally and mom being... | 5 Consult - History and Phy. |
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... | 38 Surgery |
The right eardrum is intact showing a successful tympanoplasty. I cleaned a little wax from the external meatus. The right eardrum might be very slightly red but not obviously infected. The left eardrum not the surgical ear has a definite infection with a reddened bulging drum but no perforation or granulation tis... | 25 Office Notes |
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 photophobi... | 15 General Medicine |
REASON FOR CONSULTATION Pulmonary embolism. HISTORY The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy had some cold sweats mild shortness of breath no chest p... | 5 Consult - History and Phy. |
DIAGNOSIS T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation completed June 2006 status post 2 cycles carboplatin/5-FU given as adjuvant therapy completed September 2006 hearing loss related to chemotherapy and radiation xerostomia history o... | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSES 1. Empyema thoracis. 2. Need for intravenous antibiotics. POSTOPERATIVE DIAGNOSES 1. Empyema thoracis. 2. Need for intravenous antibiotics. PROCEDURE Central line insertion. DESCRIPTION OF PROCEDURE With the patient in his room after obtaining the informed consent his left deltopector... | 3 Cardiovascular / Pulmonary |
CC Intermittent binocular horizontal vertical and torsional diplopia. HX 70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91 he began experiencing intermittent binocular horizontal vertical and torsional diplopia which was worse and frequent at the end of the day and was ... | 22 Neurology |
DIAGNOSIS Left breast adenocarcinoma stage T3 N1b M0 stage IIIA. She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes. CURRENT MEDICATIONS 1. Glucosamine complex. 2. Toprol XL. 3. Alprazolam 4. Hydrochlorothiaz... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS Rejection of renal transplant. POSTOPERATIVE DIAGNOSIS Rejection of renal transplant. OPERATIVE PROCEDURE Transplant nephrectomy. DESCRIPTION OF PROCEDURE The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago. The patient was recentl... | 21 Nephrology |
Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history bec... | 27 Orthopedic |
ADMISSION DIAGNOSES 1. Menometrorrhagia. 2. Dysmenorrhea. 3. Small uterine fibroids. DISCHARGE DIAGNOSES 1. Menorrhagia. 2. Dysmenorrhea. 3. Small uterine fibroids. OPERATION PERFORMED Total vaginal hysterectomy. BRIEF HISTORY AND PHYSICAL The patient is a 42 year-old white female gravida 3 para 2 with... | 10 Discharge Summary |
TITLE OF OPERATION Diagnostic laparoscopy. INDICATION FOR SURGERY The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy. PREOP DIAGNOSIS Possible ruptured ectopic pregnancy. POSTOP DIAGNOSIS No evidence of ectopic pregnancy or ruptured ectopic pregnancy. ANESTHESIA General endotra... | 24 Obstetrics / Gynecology |
REASON FOR CONSULTATION I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer. HISTORY OF PRESENT ILLNESS The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time she was pregnant and was unsure if her symptoms migh... | 5 Consult - History and Phy. |
GENERAL Well developed well nourished alert in no acute distress. GCS 50 nontoxic. VITAL SIGNS Blood pressure pulse respirations temperature degrees F. Pulse oximetry . HEENT Eyes Lids and conjunctiva. No lesions. Pupils equal round reactive to light and accommodation. Irises symmetric... | 15 General Medicine |
DISCHARGE DISPOSITION The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice. DISCHARGE DIAGNOSES AXIS I Schizoaffective disorder bipolar type. AXIS II Deferred. AXIS III Hepatitis C. AXIS IV Severe. AXIS V 19. CONDITION OF PATIENT ON DISCHARGE Th... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Left mesothelioma focal. POSTOPERATIVE DIAGNOSIS Left pleural-based nodule. PROCEDURES PERFORMED 1. Left thoracoscopy. 2. Left mini thoracotomy with resection of left pleural-based mass. FINDINGS Left anterior pleural-based nodule which was on a thin pleural pedicle with no invasion... | 3 Cardiovascular / Pulmonary |
HISTORY The patient is a 67-year-old female was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. At the onset of therapy on 03/26/08 the patient was NPO with a G-tube and the initial spe... | 10 Discharge Summary |
HISTORY OF PRESENT ILLNESS This 57-year-old black female was seen in my office on Month DD YYYY for further evaluation and management of hypertension. Patient has severe backache secondary to disc herniation. Patient has seen an orthopedic doctor and is scheduled for surgery. Patient also came to my office for s... | 25 Office Notes |
REASON FOR EXAM Coronary artery bypass surgery and aortic stenosis. FINDINGS Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50 to 55 . Concentric hypertrophy noted with interventricu... | 33 Radiology |
ADMITTING DIAGNOSES Left renal cell carcinoma left renal cyst. DISCHARGE DIAGNOSIS Left renal cell carcinoma left renal cyst. SECONDARY DIAGNOSES 1. Chronic obstructive pulmonary disease. 2. Coronary artery disease. PROCEDURES Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy. HIS... | 21 Nephrology |
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 th... | 7 Dentistry |
INDICATIONS Atrial fibrillation coronary disease. STRESS TECHNIQUE The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation. IMAGE TECHNIQUE The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT... | 3 Cardiovascular / Pulmonary |
EXAM MRI LEFT SHOULDER CLINICAL This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear. FINDINGS Examination was performed on 9/1/05. There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface extending into the myotendinous junc... | 27 Orthopedic |
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 ... | 38 Surgery |
SUBJECTIVE This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently. CURRENT MEDICATIONS ... | 15 General Medicine |
PROCEDURES PERFORMED Endoscopy. INDICATIONS Dysphagia. POSTOPERATIVE DIAGNOSIS Esophageal ring and active reflux esophagitis. PROCEDURE Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 m... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Blood loss anemia. POSTOPERATIVE DIAGNOSES 1. Normal colon with no evidence of bleeding. 2. Hiatal hernia. 3. Fundal gastritis with polyps. 4. Antral mass. ANESTHESIA Conscious sedation with Demerol and Versed. SPECIMEN Antrum and fundal polyps. HISTORY The patient is a 66-year-o... | 14 Gastroenterology |
EXAM MRI-UP EXT JOINT LEFT SHOULDER CLINICAL Left shoulder pain. Evaluate for rotator cuff tear. FINDINGS Multiple T1 and gradient echo axial images were obtained as well as T1 and fat suppressed T2-weighted coronal images. The rotator cuff appears intact and unremarkable. There is no significant effusion seen. O... | 27 Orthopedic |
EXAM Skull complete five images HISTORY Plagiocephaly. TECHNIQUE Multiple images of the skull were evaluated. There are no priors for comparison. FINDINGS Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure. There is n... | 29 Pediatrics - Neonatal |
REASON FOR VISIT Overactive bladder with microscopic hematuria. HISTORY OF PRESENT ILLNESS The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during... | 35 SOAP / Chart / Progress Notes |
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... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Jaw pain this morning. BRIEF HISTORY OF PRESENT ILLNESS This is a very nice 53-year-old white male with no previous history of heart disease was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia presently on Lipitor 20 mg a day and hyperthyroid... | 5 Consult - History and Phy. |
HISTORY OF PRESENT ILLNESS The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago. The patient last year developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction. The patient again went into complete remission. The patient has been doing ... | 5 Consult - History and Phy. |
Sample Address RE Sample Patient Dear Doctor We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing cough and shortness of breath over... | 29 Pediatrics - Neonatal |
CHIEF COMPLAINT Followup of hospital discharge for Guillain-Barre syndrome. HISTORY OF PRESENT ILLNESS This is a 62-year-old right-handed woman with hypertension diabetes mellitus a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had ons... | 5 Consult - History and Phy. |
PROCEDURE PERFORMED 1. Right femoral artery access. 2. Selective right and left coronary angiogram. 3. Left heart catheterization. 4. Left ventriculogram. INDICATIONS FOR PROCEDURE A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery pres... | 38 Surgery |
PROCEDURES PERFORMED C5-C6 anterior cervical discectomy allograft fusion and anterior plating. ESTIMATED BLOOD LOSS 10 mL. CLINICAL NOTE This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain. We decided go ahead with a... | 23 Neurosurgery |
PREOPERATIVE DIAGNOSIS Adenotonsillar hypertrophy and chronic otitis media. POSTOPERATIVE DIAGNOSIS Adenotonsillar hypertrophy and chronic otitis media. PROCEDURE PERFORMED 1. Tympanostomy and tube placement. 2. Adenoidectomy. ANESTHESIA General endotracheal. DESCRIPTION OF PROCEDURE The patient was take... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck. POSTOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck. OPERATION PERFORMED Left neck dissection. ANESTHESIA General endotracheal. INDICATIONS The patient is a very nice gentleman who has had thyroid cancer papillary cell type remo... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSES 1. Maxillary atrophy. 2. Severe mandibular atrophy. 3. Acquired facial deformity. 4. Masticatory dysfunction. POSTOPERATIVE DIAGNOSES 1. Maxillary atrophy. 2. Severe mandibular atrophy. 3. Acquired facial deformity. 4. Masticatory dysfunction. PROCEDURE PERFORMED Autologous iliac cre... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Benign prostatic hyperplasia. POSTOPERATIVE DIAGNOSIS Benign prostatic hyperplasia. OPERATION PERFORMED Transurethral electrosurgical resection of the prostate. ANESTHESIA General. COMPLICATIONS None. INDICATIONS FOR THE SURGERY This is a 77-year-old man with severe benign prost... | 38 Surgery |
CHIEF COMPLAINT Abdominal pain and discomfort for 3 weeks. HISTORY OF PRESENT ILLNESS The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdom... | 15 General Medicine |
CHIEF COMPLAINT Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant 61-year-old obese African-American male with a past medical history significant for hypertension who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the ... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Fracture dislocation C2. POSTOPERATIVE DIAGNOSIS Fracture dislocation C2. OPERATION PERFORMED 1. Open reduction and internal fixation ORIF of comminuted C2 fracture. 2. Posterior spinal instrumentation C1-C3 using Synthes system. 3. Posterior cervical fusion C1-C3. 4. Insertion of ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder. POSTOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder. PROCEDURE PERFORMED Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder. PRO... | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye the double vision dis... | 22 Neurology |
POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers. The patient has been asked to restrict the use of the extremity for the next 24 hours. | 28 Pain Management |
PREOPERATIVE DIAGNOSES 1. Eyebrow ptosis. 2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid. 3. Cervical facial aging with submental lipodystrophy. OPERATION 1. Hairline biplanar temporal browlift. 2. Quadrilateral blepharoplasty with lateral canthopexy with arcus margi... | 26 Ophthalmology |
HISTORY OF PRESENT ILLNESS This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease. His creatinine has ranged between 4 and 4.5 over the past 6 months since I have been following him. I have been trying to get him educated abou... | 21 Nephrology |
PREOPERATIVE DIAGNOSIS Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE 1. Nerve root decompression at L45 on the left side. 2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. ... | 33 Radiology |
HISTORY OF PRESENT ILLNESS The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup. Her last cycle of chemotherapy was finished on 01/18/08 and she complains about some numbness in her right uppe... | 16 Hematology - Oncology |
REASON FOR CONSULTATION Regarding weakness and a history of polymyositis. HISTORY OF PRESENT ILLNESS The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which per her account did show an abnor... | 5 Consult - History and Phy. |
HISTORY OF PRESENT ILLNESS The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. Since undergoing CyberKnife treatm... | 35 SOAP / Chart / Progress Notes |
REASON FOR CONSULTATION Pneumothorax and subcutaneous emphysema. HISTORY OF PRESENT ILLNESS The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pa... | 3 Cardiovascular / Pulmonary |
Thereafter he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5 2008 Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X. Thereafter he did an extensive course of physical therapy work harden... | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night after she states she drank lots of red wine. She states after vomiting she felt fine through the night but woke with more nausea and v... | 5 Consult - History and Phy. |
CHIEF COMPLAINT 1. Extensive stage small cell lung cancer. 2. Chemotherapy with carboplatin and etoposide. 3. Left scapular pain status post CT scan of the thorax. HISTORY OF PRESENT ILLNESS The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment wit... | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSIS Bilateral undescended testes. POSTOPERATIVE DIAGNOSIS Bilateral undescended testes bilateral intraabdominal testes. PROCEDURE Examination under anesthesia and laparoscopic right orchiopexy. ESTIMATED BLOOD LOSS Less than 5 mL. FLUIDS RECEIVED 110 mL of crystalloid. INTRAOPERATIVE ... | 39 Urology |
CURRENT MEDICATIONS Lortab. PREVIOUS MEDICAL HISTORY Cardiac stent in 2000. PATIENT S GOAL To eat again by mouth. STUDY A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed ... | 14 Gastroenterology |
CHIEF COMPLAINT Weak and shaky. HISTORY OF PRESENT ILLNESS The patient is a 75-year-old Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough hemoptysis dyspn... | 5 Consult - History and Phy. |
OPERATION 1. Right upper lung lobectomy. 2. Mediastinal lymph node dissection. ANESTHESIA 1. General endotracheal anesthesia with dual-lumen tube. 2. Thoracic epidural. OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of t... | 38 Surgery |
CT HEAD WITHOUT CONTRAST CT FACIAL BONES WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision. CT HEAD TECHNIQUE Noncontrast axial CT images of the head were obtained without contrast. FINDINGS There is no acute intracranial hemorrhage mass effect midline shift o... | 33 Radiology |
PROCEDURES PERFORMED Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles. PROCEDURE CODES 64640 times one 64614 times two 95873 times two. PREOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 34... | 23 Neurosurgery |
TECHNIQUE Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. FINDINGS The cervical spine demonstrates normal alignment and mineralizatio... | 33 Radiology |
ADMISSION DIAGNOSIS End-stage renal disease ESRD . DISCHARGE DIAGNOSIS End-stage renal disease ESRD . PROCEDURE Cadaveric renal transplant. HISTORY OF PRESENT ILLNESS This is a 46-year-old gentleman with end-stage renal disease ESRD secondary to diabetes and hypertension who had been on hemodialysis si... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Right hip osteoarthritis. POSTOPERATIVE DIAGNOSIS Right hip osteoarthritis. PROCEDURES PERFORMED Total hip replacement on the right side using the following components 1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o clock position. 2. Trabecular metal mo... | 27 Orthopedic |
REASON FOR CONSULTATION Lethargy. HISTORY OF PRESENT ILLNESS The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE DVT hyperlipidemia and hypertension who is according to the patient s daughter expressing signs of depressi... | 32 Psychiatry / Psychology |
PROCEDURE PERFORMED 1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter. 2. Surgeon-interpreted fluoroscopy. OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient ... | 3 Cardiovascular / Pulmonary |
PREPROCEDURE DIAGNOSIS Abdominal pain diarrhea and fever. POSTPROCEDURE DIAGNOSIS Pending pathology. PROCEDURES PERFORMED Colonoscopy with multiple biopsies including terminal ileum cecum hepatic flexure and sigmoid colon. | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Right middle lobe lung cancer. POSTOPERATIVE DIAGNOSIS Right middle lobe lung cancer. PROCEDURES PERFORMED 1. VATS right middle lobectomy. 2. Fiberoptic bronchoscopy thus before and after the procedure. 3. Mediastinal lymph node sampling including levels 4R and 7. 4. Tube thoracostomy ... | 38 Surgery |
PROCEDURE DONE Resting Myoview and adenosine Myoview SPECT. INDICATIONS Chest pain. PROCEDURE 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute ov... | 33 Radiology |
OPERATIVE PROCEDURES Colonoscopy and biopsies epinephrine sclerotherapy hot biopsy cautery and snare polypectomy. PREOPERATIVE DIAGNOSES 1. Colon cancer screening. 2. Family history of colon polyps. POSTOPERATIVE DIAGNOSES 1. Multiple colon polyps 5 . 2. Diverticulosis sigmoid colon. 3. Internal hemorrho... | 14 Gastroenterology |
REASON FOR CONSULTATION Followup of seizures. HISTORY OF PRESENT ILLNESS This is a 47-year-old African-American female well known to the neurology service who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002. At that time she had one... | 5 Consult - History and Phy. |
INDICATION Lung carcinoma. Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial coronal and sagittal imaging was performed over the neck chest abdomen and pelvis. FINDINGS There is normal physiologic activity identified in the myocardium liver spleen ureters kidneys and bladder. There is abnorma... | 33 Radiology |
SUBJECTIVE The patient is here for a follow-up. The patient has a history of lupus currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. S... | 34 Rheumatology |
CHIEF COMPLAINT Arm and leg jerking. HISTORY OF PRESENT ILLNESS The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea perioral cyanosis or color changes. These mo... | 5 Consult - History and Phy. |
REASON FOR CONSULT Medical management status post left total knee arthroplasty. PAST MEDICAL HISTORY 1. Polyarthritis. 2. Acromegaly. 3. Hypothyroidism. 4. Borderline hypertension. 5. Obesity. PAST SURGICAL HISTORY Hernia repair resection of tumor right thumb arthrodesis carpal tunnel decompression bil... | 5 Consult - History and Phy. |
CC Seizure D/O HX 29 y/o male with cerebral palsy non-shunted hydrocephalus spastic quadriplegia mental retardation bilateral sensory neural hearing loss severe neurogenic scoliosis and multiple contractures of the 4 extremities neurogenic bowel and bladder incontinence and a history of seizures. He was seen... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Wrist de Quervain stenosing tenosynovitis. POSTOPERATIVE DIAGNOSIS Wrist de Quervain stenosing tenosynovitis. TITLE OF PROCEDURES 1. de Quervain release. 2. Fascial lengthening flap of the 1st dorsal compartment. ANESTHESIA MAC. COMPLICATIONS None. PROCEDURE IN DETAIL After MAC an... | 27 Orthopedic |
PROCEDURE PERFORMED Laparoscopic cholecystectomy. PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile mann... | 38 Surgery |
CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain with swelling at the site of the ileostomy. TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. CT ABDOMEN The liver spleen pancreas adrenal glands and kidneys are u... | 33 Radiology |
HISTORY OF PRESENT ILLNESS This is a 55-year-old female with a history of stroke who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improve... | 39 Urology |
CC Lethargy. HX This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95 his partner found him markedly lethargic and complaingin of... | 22 Neurology |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.