smoh/medical-transcriptions huggingface dataset:
Upper Endoscopy - Foreign Body Removal  ( Gastroenterology)
Description:  Upper endoscopy with foreign body removal (Penny in proximal esophagus).

PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.
Air Under Diaphragm - Consult  ( General Medicine)
Description:  Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology.

REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.
Umbilical Hernia Repair - 1  ( Gastroenterology)
Description:  Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  

PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
Acute Cystitis & Diabetes Type II  ( General Medicine)
Description:  The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.
Accidental Celesta Ingestion - ER Visit  ( General Medicine)
Description:  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.

HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills "didn't taste good," so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.
Viral Gastroenteritis  ( Gastroenterology)
Description:  Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill.

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 vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.
Upper Endoscopy   ( Gastroenterology)
Description:  Upper endoscopy with removal of food impaction.

PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.
Ttriple-Lumen Central Line  ( Gastroenterology)
Description:  Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. 

PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.
Ultrasound - Abdomen - 1  ( Gastroenterology)
Description:  Ultrasound Abdomen - elevated liver function tests.

EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration.  The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed.  There is dilatation of the common bile duct up to 1 cm.  There is also dilatation of the pancreatic duct that measures up to 3 mm.  There is caliectasis in the right kidney.  The bladder is significantly distended measuring 937 cc in volume.  The caliectasis in the right kidney may be secondary to back pressure from the distended bladder.  The aorta is normal in caliber., ,IMPRESSION:,1.  Dilated common duct as well as pancreatic duct as described.  Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass.  The findings could reflect changes of cholecystectomy.  ,2.  Significantly distended bladder with probably resultant caliectasis in the right kidney.  Clinical correlation recommended.
Ultrasound - Abdomen  ( Gastroenterology)
Description:  Ultrasound abdomen, complete

EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  The patient has diffuse abdominal pain.  There is a history of AIDS.,TECHNIQUE:,  An ultrasound examination of the abdomen was performed.,FINDINGS:,  The liver has normal echogenicity.  The liver is normal sized.  The gallbladder has a normal appearance without gallstones or sludge.  There is no gallbladder wall thickening or pericholecystic fluid.  The common bile duct has a normal caliber at 4.6 mm.  The pancreas is mostly obscured by gas.  A small portion of the head of pancreas is visualized which has a normal appearance.  The aorta has a normal caliber.  The aorta is smooth walled.  No abnormalities are seen of the inferior vena cava.  The right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  No masses, cysts, calculi, or hydronephrosis is seen.  There is normal renal cortical echogenicity.  The spleen is somewhat prominent with a maximum diameter of 11.2 cm.  There is no ascites.  The urinary bladder is distended with urine and shows normal wall thickness without masses.  The prostate is normal sized with normal echogenicity.,IMPRESSION:  ,1.  Spleen size at the upper limits of normal.,2.  Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  The visualized portion of the head had a normal appearance.,3.  The gallbladder has a normal appearance without gallstones.  There are no renal calculi.
Umbilical Hernia Repair  ( Gastroenterology)
Description:  Umbilical hernia repair template.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.

PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.
Surgical Closure of Gastrostomy  ( Gastroenterology)
Description:  Closure of gastrostomy placed due to feeding difficulties. 

PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.