smoh/medical-transcriptions huggingface dataset:
SAH, Contusion, Skull Fracture  ( Radiology)
Description:  HCT: SAH, Contusion, Skull fracture

CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.
Single Frontal View of Chest  ( Radiology)
Description:  Chest, Single view post OP for ASD (Atrial Septal Defect).

EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis.  Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:,  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.
Single Frontal View - Chest - Pediatric  ( Radiology)
Description:  Single frontal view of the chest. Respiratory distress.  The patient has a history of malrotation.

EXAM:,  Single frontal view of the chest.,HISTORY:,  Respiratory distress.  The patient has a history of malrotation.  The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:,  Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:,  A single frontal view of the chest was evaluated.  It reveals interval placement of an ET tube and an NG tube.  ET tube is midway between the patient's thoracic inlet and carina.  NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm.  There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.  The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique.  There is a slight increase seen with regards to the central pulmonary vessels.  Again, this may represent a minimal amount of pulmonary vascular congestion.  There is paucity of bowel gas seen in the upper abdomen.  The osseous thorax appears to be grossly intact and symmetrical.  Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1.  No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2.  Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3.  Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.
Renal Ultrasound  ( Radiology)
Description:  Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy

EXAM:,  Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:,  Most recently obtained mm/dd/yy.,FINDINGS:,  The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1.  No evidence of hydronephrosis.,2.  Mass within the right lobe of the liver.  The patient apparently has a severe iodine allergy.  Further evaluation with MRI is recommended.,3.  The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,
Radionuclide Stress Test  ( Radiology)
Description:  Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.

INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.
Radiofrequency Thermocoagulation - 1  ( Radiology)
Description:  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.
Renal Ultrasound - 1  ( Radiology)
Description:  Bilateral renal ultrasound.

EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual.
Radiofrequency Thermocoagulation  ( Radiology)
Description:  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.
Radiologic Exam - Spine   ( Radiology)
Description:  Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.

EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.
Prostate Brachytherapy  ( Radiology)
Description:  Prostate Brachytherapy - Prostate I-125 Implantation

PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.
Right Foot Series  ( Radiology)
Description:  Right foot series after a foot injury.

EXAM: , Right foot series.,REASON FOR EXAM:  ,Injury.,FINDINGS: , Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.
Paracentesis - Ultrasound-Guided  ( Radiology)
Description:  Ultrasound-Guided Paracentesis for Ascites

EXAM:,  Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS:  ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained.  Ultrasound demonstrates free fluid in the abdomen.  The area of interest was localized with ultrasonography.  The region was sterilely prepped and draped in the usual manner.  Local anesthetic was administered.  A 5-French Yueh catheter needle combination was taken.  Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle.  A total of approximately 5500 mL of serous fluid was obtained.  The catheter was then removed.  The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.
Nuclear Medicine Lymphatic Scan  ( Radiology)
Description:  Left breast cancer.  Nuclear medicine lymphatic scan.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.

EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.
Nuclear Cardiac Stress Report  ( Radiology)
Description:  Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.

NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.
PET Report - Whole Body Scan  ( Radiology)
Description:  Whole body PET scanning.

INDICATION: , Lung carcinoma.,Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis.,FINDINGS:,There is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder.,There is abnormal FDG-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an SUV of 3.8, no definite bone lesion is identified on the CT scan or the bone scan dated 08/14/2007 (It may be purely lytic).,Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18.1, the adjacent atelectasis as likely post obstructive in nature.,Additionally, although there is no definite lesion identified on CT , there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5.0. The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan.,There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3.7 in the mediastinum.,IMPRESSION:,No prior PET scans for comparison, there is a large lesion identified in the area of the left hilum with an SUV of 18.1 likely causing the obstructive atelectasis seen on the CT scan.,There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5.0.,There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. However no lesion is identified on bone scan or CT scan.,There is a hypermetabolic lymph node identified. The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3.7.
Nuclear Medicine Tumor Localization  ( Radiology)
Description:  Nuclear medicine tumor localization, whole body - status post subtotal thyroidectomy for thyroid carcinoma.

EXAM:,  Nuclear medicine tumor localization, whole body.,HISTORY: , Status post subtotal thyroidectomy for thyroid carcinoma, histology not provided.,FINDINGS: , Following the oral administration of 4.3 mCi Iodine-131, whole body planar images were obtained in the anterior and posterior projections at 24, 48, and 72 hours.,There is increased uptake in the left upper quadrant, which persists throughout the examination.  There is a focus of increased activity in the right lower quadrant, which becomes readily apparent at 72 hours.  Physiologic uptake in the liver, spleen, and transverse colon is noted.  Physiologic urinary bladder uptake is also appreciated.  There is low-grade uptake in the oropharyngeal region.,IMPRESSION:  ,Iodine-avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis.  Anatomical evaluation, i.e., CT is advised to determine if there are corresponding mesenteric lesions.  Ultimately (provided that the original pathology of the thyroid tumor with iodine-avid) PET scanning may be necessary.  No evidence of iodine added locoregional metastasis.
Myoview Perfusion Scan  ( Radiology)
Description:  Resting Myoview perfusion scan and gated myocardial scan.  Findings consistent with an inferior non-transmural scar

INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.