smoh/medical-transcriptions huggingface dataset:
D&C - Discharge Summary  ( Obstetrics / Gynecology)
Description:  Hysteroscopy, dilatation and curettage (D&C), and myomectomy.  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,OPERATIONS PERFORMED:,1.  Hysteroscopy.,2.  Dilatation and curettage (D&C).,3.  Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed.  Hysteroscopy revealed a large endometrial cavity fibroid.  Careful shaving and excision of this fibroid was performed with removal of the fibroid.  Hemostasis was noted completely at the end of this procedure.  Postoperatively, the patient has done well.  The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  The patient is now ambulating without difficulty and tolerating her diet.  The patient desires to go home.  The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:  ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  Ambulate with assistance at home only.  The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care.  The patient was given full and complete postop and discharge instructions.  All her questions were answered.
D&C & Hysteroscopy Followup  ( Obstetrics / Gynecology)
Description:  D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.

PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.
Consult/ER Report - OB/GYN  ( Obstetrics / Gynecology)
Description:  A female with unknown gestational age who presents to the ED after a suicide attempt.

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
CT Abdomen & Pelvis - OB-GYN  ( Obstetrics / Gynecology)
Description:  Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast.

EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.
Complete Physical - Female  ( Obstetrics / Gynecology)
Description:  An 18-year-old white female who presents for complete physical, Pap, and breast exam.

SUBJECTIVE:,  This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college.  She denies any problems at this time.  Her last Pap smear was 06/25/2003 and was normal.  She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.  We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:,  Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Denies tobacco or drug use, rare alcohol use.  She is sexually active and has had one partner.,FAMILY HISTORY:  ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs:  Height 5 feet 6 inches.  Weight 153 pounds.  Blood pressure 106/72.  Pulse 68.  Respirations 12.  Temperature 97.5.  Last menstrual period 05/30/2004.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Tympanic membranes unremarkable.  Oropharynx nonerythematous.  Pupils equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No lymphadenopathy and no thyromegaly.,Chest:  Clear to auscultation bilaterally.,CV:  Regular rate and rhythm without murmur.,Abdomen:  Positive bowel sounds.  Soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Normal vaginal rugation.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Extremities:  No cyanosis, clubbing, or edema.,Neurologic:  2+/4 DTRs in all extremities.  5/5 motor strength in all extremities.  Negative Romberg.,Musculoskeletal:  No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1.  Complete physical, Pap, and breast exam completed.,2.  School physical form completed and returned to the patient.,3.  Hepatitis B second injection will be given today.,4.  Contraceptive surveillance.  We will put patient to Seasonale to start at the end of this cycle a pill.,5.  Allergic rhinitis.  Prescription was given for Allegra 180 mg q.d.  #30 carrying refills for her to take with her school Cowley County Community College.,6.  Insomnia.  Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school.  She will follow up as needed.
Cone Biopsy  ( Obstetrics / Gynecology)
Description:  Cervical cone biopsy, dilatation & curettage

PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:,  Cervical cone biopsy, dilatation & curettage.,SPECIMENS:  ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ.  The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered and she was placed in the lithotomy position.  The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  A Kevorkian curette was used to obtain endocervical curettings.  The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture.  Upon completion of the suture placement, the endocervical canal was sounded to assure patency.  A prophylactic application of Monsel's solution completed the procedure.  ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  Final sponge, needle, and instrument counts were.
Colpocleisis  ( Obstetrics / Gynecology)
Description:  Colpocleisis and rectocele repair.

PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.
Cholestasis Of Pregnancy   ( Obstetrics / Gynecology)
Description:  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.

FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.
Breast Mass Excision - 2  ( Obstetrics / Gynecology)
Description:  Excision of left breast mass.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin. 

PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:,  Breast mass, left.,PROCEDURE:,  Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  The time-out process was followed.  Preoperative antibiotic was given.  The patient was prepped and draped in the usual fashion.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.  An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  Hemostasis was achieved with the cautery.  The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl.  A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.
Breast Radiation Therapy Followup  ( Obstetrics / Gynecology)
Description:  Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.

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.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.
Cesarean Section  ( Obstetrics / Gynecology)
Description:  Cesarean Section.  An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum.