smoh/medical-transcriptions huggingface dataset:
Adrenalectomy & Umbilical Hernia Repair  ( Surgery)
Description:  Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.

PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
Adenoidectomy  ( Surgery)
Description:  Adenoidectomy procedure

ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.
Adenotonsillectomy - 2  ( Surgery)
Description:  Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.

POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
Adenotonsillectomy - 1  ( Surgery)
Description:  Adenotonsillectomy.  Recurrent tonsillitis.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed. 

PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.
Adenoidectomy & Tonsillectomy & Lingual Frenulectomy  ( Surgery)
Description:  Adenoidectomy and tonsillectomy and lingual frenulectomy.   Chronic adenotonsillitis and ankyloglossia.

PREOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,PROCEDURE PERFORMED:,1.  Adenoidectomy and tonsillectomy.,2.  Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:,  Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION:  ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A curved hemostat was used to grasp the lingual frenulum.  The stat was removed and Metzenbaum scissors were used to free the lingual frenulum.  Cautery was used to allow hemostasis.  The patient was then turned.  McIvor mouth gag was inserted.  Tonsils and adenoids were exposed.  The patient's right tonsil was first grasped with a curved hemostat.  Needle tip cautery was used to free the superior pole of tonsil.  The tonsil was then grasped in medial superior aspect with a straight hemostat.  The tonsil fascia planes were identified with Bovie dissection along the plane.  The tonsil was freed from anterior pillar and posterior pillar.  Amputation occurred along the same plane as the patient's tongue.  Suction cautery was then used to allow for hemostasis.  The patient's adenoids were then viewed with an adenoid mirror.  An adenoid curet was used to remove the patient's adenoid tissue.  Specimen sent.  Suction cautery was used to allow for hemostasis.  Superior pole of left tonsil was then grasped with a curved hemostat.  Superior pole was freed using needle tip Bovie dissection.  Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars.  The tonsil was then amputated at the same plane as tongue base.  Hemostasis was achieved with using suction cautery.  Mouth gag was removed.  Dual position and occlusion were tested.  The patient was extubated and tolerated the procedure well and sent back to PACU.
AC Separation Revision & Hardware Removal  ( Surgery)
Description:  Removal of the hardware and revision of right AC separation.  Loose hardware with superior translation of the clavicle implants.  Arthrex bioabsorbable tenodesis screws.

PREOPERATIVE DIAGNOSIS:,  Right AC separation.,POSTOPERATIVE DIAGNOSIS:,  Right AC separation.,PROCEDURES:,  Removal of the hardware and revision of right AC separation.,ANESTHESIA:,  General.,BLOOD LOSS:,  100 cc.,COMPLICATIONS:,  None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  The incision was reopened and the hardware was removed without difficulty.  The AC joint was inspected and reduced.  An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.
Abscess Excision  ( Surgery)
Description:  Excision of abscess, removal of foreign body.  Repair of incisional hernia.  Recurrent re-infected sebaceous cyst of abdomen.  Abscess secondary to retained foreign body and incisional hernia.

PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Abscess secondary to retained foreign body.,2.  Incisional hernia.,PROCEDURES,1.  Excision of abscess, removal of foreign body.,2.  Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma.  The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill.  He presented to my office and I recommended that he undergo exploration of this area and removal.  The procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,FINDINGS:,  The patient was found upon excision of the cyst that it contained a large Prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,DESCRIPTION OF PROCEDURE: , The patient was identified, then taken into the operating room, where after induction of an LMA anesthetic, his abdomen was prepped with Betadine solution and draped in sterile fashion.  The puncta of the wound lesion was infiltrated with methylene blue and peroxide.  The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base.  In doing so, we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia.  The cyst was removed in its entirety, divided from the omentum using a Metzenbaum and tying with 2-0 silk ties.  The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures.  The wound was then irrigated and closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular and Steri-Strips.  Patient tolerated the procedure well.  Dressings were applied and he was taken to recovery room in stable condition.
Abdominal Abscess I&D  ( Surgery)
Description:  Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.

PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  Came in approximately 36 hours ago with pain across his lower abdomen.  CT scan demonstrated presence of an abscess beneath the incision.  I recommended to the patient he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.,FINDINGS:,  The patient was found to have an abscess that went down to the level of the fascia.  The anterior layer of the fascia was fibrinous and some portions necrotic.  This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.,TECHNIQUE:  ,Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion.  The wound opening where it was draining was explored using a curette.  The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained.  I then noted that there was a significant amount of undermining.  These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia.  The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  A dressing was applied.  The finished wound size was 9.0 x 5.3 x 5.2 cm in size.  Patient tolerated the procedure well.  Dressing was applied, and he was taken to recovery room in stable condition.
Speech Therapy - Discharge Summary  ( Speech - Language)
Description:  Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. 

LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.
Speech Therapy - Discharge Summary - 2  ( Speech - Language)
Description:  The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke.  The patient attended nine outpatient skilled speech therapy sessions.

The patient made some progress during therapy.  She accomplished two and a half out of her five short-term therapy goals.  We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  Her last session occurred on 01/09/09.  She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.
Cognitive Linguistic Impairment - Discharge  ( Speech - Language)
Description:  Cognitive linguistic impairment secondary to stroke.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  

DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:,  5,HOSPITAL COURSE:  ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall.  The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities.  At this time, the patient has accomplished all 5 of her short-term therapy goals.  She is able to complete functional mass tasks with 100% accuracy independently.  She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently.  She is able to state 15 items in a broad category within a minute and a half independently.  The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently.  The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home.  The patient is no longer in need of skilled speech therapy and is discharged from my services.  She did quite well in therapy and also agreed with this discharge.
Uterine Papillary Serous Carcinoma  ( SOAP / Chart / Progress Notes)
Description:  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. 

HISTORY OF PRESENT ILLNESS:,  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.  Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity.  This has not gotten worse recently and there is no numbness in her toes.  She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria.  The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg.  GENERAL:  She is a middle-aged white female, not in any distress.  HEENT:  No lymphadenopathy or mucositis.  CARDIOVASCULAR:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  EXTREMITIES:  No cyanosis, clubbing or edema.  NEUROLOGICAL:  No focal deficits noted.  PELVIC:  Normal-appearing external genitalia.  Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff.  No local or distant metastasis.  Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy.  She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1.  Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2.  The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3.  The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4.  The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,
Weight Loss on Phentermine  ( SOAP / Chart / Progress Notes)
Description:  Followup on weight loss on phentermine.

SUBJECTIVE:,  She is here for a followup on her weight loss on phentermine.  She has gained another pound since she was here last.  We talked at length about the continued plateau she has had with her weight.  She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136.  She is frustrated with this as well.  We agree that if she continues to plateau she really should not stay on phentermine.  We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees.,REVIEW OF SYSTEMS:,  Otherwise negative.  She has no specific complaints.  No shortness of breath, chest pain or palpitations.,PHYSICAL EXAM:,Vital signs:  Her blood pressure is fine.  Her diastolic is a little bit high, but otherwise okay.,General:  She appears in good spirits.  No apparent distress.,HEENT:  Negative.,Neck:  Supple without bruits.,Chest:  Clear.,Cardiac exam:  Regular without extra sounds.,ASSESSMENT:,  Weight loss on phentermine, really has plateaued.,PLAN:,  If she does not lose weight in the next month we will probably consider having her go off the phentermine.  If she does lose a couple of pounds, then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop.  She agrees with this plan.