smoh/medical-transcriptions huggingface dataset:
CT Brain: Subdural hematoma  ( Radiology)
Description:  CT of Brain - Subacute SDH.

CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.
CT Chest - 1  ( Radiology)
Description:  CT chest with contrast.

EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe.  There are linear fibrotic or atelectatic changes associated with this.  Recommend followup to ensure resolution.  There is left apical scarring.  There is no pleural effusion or pneumothorax.  There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid.  Cardiac and aortic contours are unremarkable aside from mild atherosclerosis.  The heart is not enlarged.  There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation.  Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.
CT Brain - SAH  ( Radiology)
Description:  CT Brain: Subarachnoid hemorrhage.

CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.
CT Brain - Hemangioma  ( Radiology)
Description:  CT Brain: Midbrain hemangioma

CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of "dystonia.",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild "ataxia" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.
CT Brain: Subdural Hemorrhage.  ( Radiology)
Description:  HCT: Subdural hemorrhage.

CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:,  BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.
CT Brain - Aneurysm  ( Radiology)
Description:  CT Brain: Suprasellar aneurysm, pre and post bleed.

CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.
CT Abdomen & Pelvis - OB-GYN  ( Radiology)
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.
CT Abdomen & Pelvis - 7  ( Radiology)
Description:  Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.

REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.
CT Abdomen & Pelvis - 8  ( Radiology)
Description:  Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.

CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.
CT Angiography  ( Radiology)
Description:  Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.   CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE:  ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS:  ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax.  No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable.  No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.
CT Abdomen & Pelvis - 5  ( Radiology)
Description:   CT abdomen without contrast and pelvis without contrast, reconstruction.

EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.
CT Angiography - 1  ( Radiology)
Description:  Shortness of breath for two weeks and a history of pneumonia.  CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.