smoh/medical-transcriptions huggingface dataset:
Phacoemulsification  ( Ophthalmology)
Description:  Phacoemulsification with posterior chamber intraocular lens - Sample/Template.

PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.
Optometry - Letter  ( Ophthalmology)
Description:  Woman with a history of macular degeneration.  PDT therapy.  Some vision therapy.  Complete refractive work-up.

RE:  Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY.  She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year.  She would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print.  At this time, she uses a small handheld magnifier, which is providing her with only limited help.,A complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye.  With a pair of +4 reading glasses, she was able to read 0.5M print quite nicely.  I have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading.  She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her.  I think that she is an excellent candidate for low vision help.  I am sure that we can be of great help to her in the near future.,Thank you for allowing us to share in the care of your patient.,With best regards,,Sample Doctor, O.D.
Ophthalmology - Letter - 2  ( Ophthalmology)
Description:  Patient being referred for evaluation of glaucoma.

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  Mr. ABC is being referred for evaluation of glaucoma.  The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally.  The patient's visual fields are full to confrontation.  Extraocular muscles are intact.  There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally.  On slit lamp examination, the patient has a normal anterior segment with 1+ nuclear sclerosis.  On dilated examination, the patient has a cup-to-disc ratio in the right eye of 0.4.  Macula, vessels, and periphery were within normal limits.  On the left eye, the patient has a cup-to-disc ratio of 0.3 and macula vessels and periphery are also within normal limits.  On gonioscopy, the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees.,In conclusion, my initial impression is that Mr. ABC does not have glaucoma.  He has fairly symmetric and small cup-to-disc ratios OU.  His intraocular pressures were within normal limits in our office today.  I discussed at length with him the alternatives of observation versus continued work-up and testing.  He seemed to understand very well and went with my recommendation to continue observation for now.  We will take fundus photos of his optic nerves for future comparison, but I think given the lack of any strong findings suspicious for glaucoma, we will defer further testing at this time.,Should you have any specific questions or any other information that you think that I may not have included in this evaluation, please feel free to contact me.  I have recommended him to follow up with you for continued examination, continued check-ups, and should you find any other abnormal findings, I would be happy to address those again.,Again, thank you for your referral of Mr. ABC.,Sincerely,,
Ophthalmology - Letter - 3  ( Ophthalmology)
Description:  Patient referred for narrow angles and possible associated glaucoma.

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma.  I examined Mrs. ABC initially on MM/DD/YYYY.  At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache.  She reports a family history of glaucoma in her mother, but is unsure of the specific kind.  Her past ocular history has been fairly unremarkable.  As you know, she has a history of non-insulin dependent diabetes.  She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me.  She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses.  Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m.  Pupillary reactions, confrontational visual fields, and ocular motility were normal.  The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure.  I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent.  I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes.  Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs.  Her intraocular pressures have remained stable.  I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care.  If I can provide any additional information or be of further service, do let me know.,Sincerely,,
Ophthalmology - Letter - 1  ( Ophthalmology)
Description:  The patient was referred for evaluation of cataracts bilaterally

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC.  The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally.  There is no relative afferent pupillary defect.  On slit lamp examination, lids and lashes were within normal limits.  The conj is quiet.  The cornea shows 1+ guttata bilaterally.  The AC is deep and quiet and irises are within normal limits bilaterally.  There is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  On dilated fundus examination, cup-to-disc ratio is 0.1 OU.  The vitreous, macula, vessels, and periphery all appear within normal limits.,Impression:  It appears that Ms. ABC' visual decline is caused by bilateral cataracts.  She would benefit from having removed.  The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy.  The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly.  I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,Again, thank you for your kind referral of this kind lady and I will be in touch with you.,Sincerely,,
Ophthalmology - Letter - 4  ( Ophthalmology)
Description:  The patient is being referred for evaluation of diabetic retinopathy.

XYZ, M.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  The patient is being referred for evaluation of diabetic retinopathy.  The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20.  The vision in the left eye is 20/20 uncorrected.  Applanation pressures are normal at 17 mmHg bilaterally.  Visual fields are full to count fingers OU and there is no relative afferent pupillary defect.  Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU.  On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally.  The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time.  We recommended him to have his eyes dilated once a year.  I have advised him to follow up with you for his regular check-ups.  Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,
Eye Examination - H&P  ( Ophthalmology)
Description:  Complete eye examination - Normal eye and vision exam.

CHIEF COMPLAINT:,  This 26-year-old male presents today for a complete eye examination.,ALLERGIES:,  Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:,  Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:,  Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:,  Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,FAMILY HISTORY:,  Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:,  Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils:  Pupil exam reveals round and equally reactive to light and accommodation.,Motility:  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields:  Confrontation VF exam reveals full to finger confrontation O.U.,IOP:  IOP Method:  applanation tonometry OD:  10 mmHg Medications:  Alphagan; 0.2% Condition:  improving.,Keratometry:,OD:  K1 35.875K2 35.875,OS:  K1 35.875K2 41.875,Lids/Orbit:  Bilateral eyes reveal normal position without infection.  Bilateral eyelids reveals white and quiet.,Slit Lamp:  Corneal epithelium is intact with normal tear film and without stain.  Stroma is clear and avascular.  Corneal endothelium is smooth and of normal appearance.,Anterior Segment:  Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens:  Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment:  Posterior segment was dilated bilateral.  Bilateral retinas reveal normal color, contour, and cupping.,Retina:  Bilateral retinas reveals flat with normal vasculature out to the far periphery.  Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected:  OD:  20/10 OS:  20/10 OU:  20/15.,REFRACTION:,Lenses - final:,OD:  +0.50 +1.50 X 125 Prism 1.75,OS:  +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add:  OD:  +1.00 OS:  +1.00,OU:  Far VA 20/25,TEST RESULTS:,  No tests to report at this time.,IMPRESSION:,  Eye and vision exam normal.,PLAN:,  Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:
Ophthalmology Progress Note - 1  ( Ophthalmology)
Description:  Ophthalmology followup visit note.

She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.
Lid Laceration Repair  ( Ophthalmology)
Description:  Repair of upper lid canalicular laceration - Sample/Template.

PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.
Electronystagmogram  ( Ophthalmology)
Description:  Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.

PROCEDURE:  ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze.  Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions.  Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus.  Saccadic movements did not reveal any evidence of dysmetria or overshoot.  Sinusoidal tracking was performed well for the patient's age.  Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands.  Therefore adequate OKNs were not achieved.  The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again.  The patient complained of severe dizziness in this position.  There was no clear-cut decremental response with repetition.  In the head hanging left position, no significant nystagmus was identified.  Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.  No other significant nystagmus was noted.  There was no evidence of clear-cut caloric stimulation abnormality.  This study would be most consistent with a right vestibular dysfunction.
Clear Corneal Temporal Incision  ( Ophthalmology)
Description:  Clear corneal temporal incision (no stitches).  A lid speculum was placed in the fissure of the right eye.

CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped.  A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic.  The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed.  The capsulorrhexis was then performed in a standard circular tear fashion.  The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag.  The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic.  The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization.  The lens was noted to center well.  The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution.  The eye was then checked and found to be watertight; therefore, no suture was used.  The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.
Eyelid Squamous Cell Carcinoma Excision  ( Ophthalmology)
Description:  Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.

PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.