harishnair04/mtsamples huggingface dataset:
Chronic Otitis Media 
Medical specialty:  Pediatrics - Neonatal
 A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. 

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.
Broviac Catheter Placement 
Medical specialty:  Pediatrics - Neonatal
 Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter.

PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.
Chest Closure 
Medical specialty:  Pediatrics - Neonatal
 Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  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.

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.
Atopic Eczema 
Medical specialty:  Pediatrics - Neonatal
 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.

SUBJECTIVE:,  This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema.  The patient’s mom is from Tanzania.  The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her.  The patient is a well-developed baby.  Appears stated age.  Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history.  No psoriasis.  No known drug allergies.,CURRENT MEDICATIONS:,  None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:,  Atopic eczema.,TREATMENT:,1.  Discussed condition and treatment with Mom.,2.  Continue bathing twice a week.,3.  Discontinue hot soapy water.,4.  Discontinue Elidel for now.,5.  Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch.  We will see her in one month if not better otherwise on a p.r.n. basis.  Send a letter to ABC Practice program.
Trigger Point Injection 
Medical specialty:  Pain Management
 Trigger Point Injection.  The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. 

OPERATION:,
Asthma in a 5-year-old 
Medical specialty:  Pediatrics - Neonatal
 Mother states he has been wheezing and coughing.

CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma."  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.
Thoracic epidural steroid injection 
Medical specialty:  Pain Management
 Thoracic epidural steroid injection without fluoroscopy.  An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.

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.
Bronchoscopy - Pediatric 
Medical specialty:  Pediatrics - Neonatal
 Flexible Bronchoscopy (pediatric)

FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.
Shoulder Pain Consult 
Medical specialty:  Pain Management
 Consultation for right shoulder pain.

CHIEF COMPLAINT:,  Right shoulder pain.,HISTORY OF PRESENT PROBLEM:
Radiofrequency Thermocoagulation 
Medical specialty:  Pain Management
 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.

PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA:  ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room in the prone position.  The back prepped with Betadine.  The patient was given sedation and monitored.  Under fluoroscopy, the right sacral alar notch was identified.  After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained.  Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected.  Coagulation was then carried out at 90oC for 90 seconds.  The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint.  Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications.  The patient was returned to outpatient recovery in stable condition.
Superior Gluteal Nerve Block 
Medical specialty:  Pain Management
 Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.

PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. Alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS. The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle, in close proximity to the Superior Gluteal Nerve. Aspiration was negative, and the mixture was easily injected. Aseptic technique was observed at all times, and there were no complications noted.,INJECTATE INCLUDED:,Methyl Prednisolone (DepoMedrol): 20 mg,Ketorolac (Toradol): 6 mg,Sarapin: 1 cc,Bupivacaine (Marcaine): Q.S.  2 cc.,The procedures, above were performed for diagnostic, as well as therapeutic purposes. This treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.,ZUNG SELF-RATING DEPRESSION SCALE© (SDS) RESULTS:, The patient scored as 'mildly depressed.,NOTE:, The pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.
Radiofrequency Thermocoagulation - 1 
Medical specialty:  Pain Management
 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.

PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE:  ,INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.
Stellate Ganglion Block 
Medical specialty:  Pain Management
 Complex regional pain syndrome, right upper extremity.  Stellate ganglion block.

PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION:,
Pain Management Progress Note 
Medical specialty:  Pain Management
 Pain management sample progress note.

DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.
Mortons Neuroma Injection  
Medical specialty:  Pain Management
 Injection of Morton's neuroma.

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.
Radiofrequency Thermocoagulation - 3 
Medical specialty:  Pain Management
 Cervical spondylosis.  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.

PREOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,OPERATION PERFORMED:,  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:,  Ralph Menard, M.D.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place.  The neck was placed in a flexed position.  The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula.  The patient was lightly sedated.  The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked.  Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points.  Once the anesthesia was established, an insulated 10-cm, 22-gauge needle with a 5-mm non-insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned.  This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle.  For C3 to C6 medial branch RFTC's, the needles are placed along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging.  For a C7 medial branch RFTC, the needle tip is positioned more superiorly such that it overlies the superior articular process.  For a C8 medial branch RFTC, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Sensory stimulation was carried out at 50 Hz from 0 to 2.0 volts.  Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve, or it caused replication of their concordant pain.  The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2.0 volts or until motor stimulation was found at that level.  If motor stimulation occurred, the needle was repositioned to abolish it but still cause concordant pain, or the RFTC was aborted at this level.,If the sensory stimulation caused concordant pain without motor stimulation, the area was then anesthetized with 1 cc of Marcaine 0.5% with 5 mg of methyl prednisolone acetate.  Once the anesthesia was established, a radiofrequency lesioning was then done at 65 degrees for 60 seconds.  The same procedure was carried out at all the affected levels.  The patient tolerated the procedure well without any difficulties or complications.