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4,800 | Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire lef... | Cardiovascular / Pulmonary | Fiberoptic Bronchoscopy with Lavage | PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respirator... | cardiovascular / pulmonary, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, v... |
4,801 | Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, righ... | Cardiovascular / Pulmonary | Femoral Artery Cannulation & Aortogram | PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD. Significant coronary artery diseas... | null |
4,802 | Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise. | Cardiovascular / Pulmonary | Exercise Stress Test - 2 | INDICATION: , This 69-year-old man is undergoing a preoperative evaluation for anticipated prostate surgery. He is having a transurethral prostate resection performed by Dr. X for treatment of severely symptomatic prostatic hypertrophy. He has recently completed radiation therapy to T11 for a plasmacytoma. He has re... | cardiovascular / pulmonary, regular rhythm, s1, s2, chest pain, hypertensive, bruce protocol, exercise stress test, blood pressure, resting electrocardiogram, anterior chest, heart rate, rhythm, electrocardiogram, stress, chest, heart |
4,803 | Chest pain. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test. | Cardiovascular / Pulmonary | Exercise Stress Test - 4 | INDICATION: , Chest pain.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring. The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90. The... | cardiovascular / pulmonary, treadmill stress test, heart rate, blood pressure, stress test, treadmill, hemodynamic, ekg, chest, |
4,804 | Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability. | Cardiovascular / Pulmonary | Fiberoptic Bronchoscopy - 1 | PREOPERATIVE DIAGNOSIS:,1. Hemoptysis.,2. History of lung cancer.,POSTOPERATIVE DIAGNOSIS:, Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:, Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:, General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COM... | cardiovascular / pulmonary, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe, |
4,805 | No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure. | Cardiovascular / Pulmonary | Exercise Stress Test - 3 | INDICATIONS: , An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure. The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia. He is... | cardiovascular / pulmonary, bruce protocol, exercise stress test, cardiac rehabilitation program, blood pressure, cardiac rehabilitation, heart rate, stress, rehabilitation, heart, atrial, |
4,806 | Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan. | Cardiovascular / Pulmonary | Exercise Stress Test | INDICATION: ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60. EKG normal sinus rhythm. The patient exercised on Bruce for 8 minutes on stage III. Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54. Total METs was 10.1. EKG revealed nonspecific ST... | cardiovascular / pulmonary, chest pain, ekg, sinus, st depression, mci, gated spect, nuclear myocardial perfusion scan, ejection fraction, myocardial perfusion, perfusion scan, heart rate, spect, stress, nuclear, chest |
4,807 | Patient in ER complaining of shortness of breath (COPD) | Cardiovascular / Pulmonary | ER Report - COPD | CHIEF COMPLAINT:, The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multipl... | null |
4,808 | Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout. | Cardiovascular / Pulmonary | Fiberoptic Bronchoscopy | PREOPERATIVE DIAGNOSIS:, Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1. Bilateral upper lobe cavitary lung masses.,2. Final pending pathology.,3. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also c... | cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe, |
4,809 | Patient complains of chest pain - possible esophageal reflux | Cardiovascular / Pulmonary | ER Report - Chest Pain | CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; howe... | null |
4,810 | A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram. | Cardiovascular / Pulmonary | Exercise Stress Test - 1 | Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of ... | cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram |
4,811 | Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy. | Cardiovascular / Pulmonary | Esophagogastrectomy, Jejunostomy, & Chest Tubes | OPERATION,1. Ivor-Lewis esophagogastrectomy.,2. Feeding jejunostomy.,3. Placement of two right-sided #28-French chest tubes.,4. Right thoracotomy.,ANESTHESIA: ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a tho... | cardiovascular / pulmonary, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach, |
4,812 | Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension. | Cardiovascular / Pulmonary | Elevated BNP - Consult | REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Card... | null |
4,813 | Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters. | Cardiovascular / Pulmonary | Endotracheal Intubation - 1 | PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE: ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total... | cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE |
4,814 | Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59% | Cardiovascular / Pulmonary | Exercise Myocardial Perfusion Study | CLINICAL INDICATION:, Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm. The patient was stressed according to Bruce protocol by Dr. X. Exercise... | cardiovascular / pulmonary, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia, |
4,815 | Echocardiographic examination. Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained. | Cardiovascular / Pulmonary | Echocardiography | REASON FOR EXAM:, CVA.,INDICATIONS: , CVA.,This is technically acceptable. There is some limitation related to body habitus.,DIMENSIONS: ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated... | cardiovascular / pulmonary, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral, |
4,816 | Endovascular Brachytherapy (EBT) | Cardiovascular / Pulmonary | Endovascular Brachytherapy | ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determ... | cardiovascular / pulmonary, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of ... |
4,817 | Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. | Cardiovascular / Pulmonary | Elevated Cardiac Enzymes | REASON FOR CONSULTATION:, Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profi... | null |
4,818 | Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. | Cardiovascular / Pulmonary | Endotracheal Intubation | PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subse... | cardiovascular / pulmonary, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma |
4,819 | Echocardiogram was performed including 2-D and M-mode imaging. | Cardiovascular / Pulmonary | Echocardiogram - 1 | EXAM:, Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are gr... | cardiovascular / pulmonary, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram, |
4,820 | Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension. | Cardiovascular / Pulmonary | Echocardiogram - 3 | REASON FOR EXAM:,1. Angina.,2. Coronary artery disease.,INTERPRETATION: ,This is a technically acceptable study.,DIMENSIONS: ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.,FINDINGS: , Left atrium was mildly to moderately dilated. No m... | cardiovascular / pulmonary, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly, |
4,821 | Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm | Cardiovascular / Pulmonary | Echocardiogram - 2 | EXAM:, Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. L... | cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic, |
4,822 | Duplex ultrasound of legs | Cardiovascular / Pulmonary | Duplex Ultrasound - Legs | DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus ... | cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins, |
4,823 | Dobutamine Stress Echocardiogram. Chest discomfort, evaluation for coronary artery disease. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate. Negative EKG criteria for ischemia. | Cardiovascular / Pulmonary | Dobutamine Stress Test - 1 | DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a d... | cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart |
4,824 | Echocardiogram with color flow and conventional Doppler interrogation. | Cardiovascular / Pulmonary | Echocardiogram | REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular s... | cardiovascular / pulmonary, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation, |
4,825 | Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement. | Cardiovascular / Pulmonary | Dual Chamber Generator Replacement | REFERRAL INDICATIONS,1. Pacemaker at ERI.,2. History AV block.,PROCEDURES PLANNED AND PERFORMED:, Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1. Ancef 1 g.,2. Versed 2 mg.,3. Fentanyl 50 mcg.,CLINICAL HISTORY: ,The patient is a pleasant patient who presented... | null |
4,826 | Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography. | Cardiovascular / Pulmonary | Dual Chamber ICD Implantation | PROCEDURE:,1. Implantation, dual chamber ICD.,2. Fluoroscopy.,3. Defibrillation threshold testing.,4. Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room. The patient was prepped and draped in a sterile fashion. Using modified Seldinger technique, the lef... | cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pec... |
4,827 | Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port. | Cardiovascular / Pulmonary | Double Lumen Port Inserstion | PREOPERATIVE DIAGNOSIS:, Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1. Open exploration of the left subclavian/axillary vein.,2. Insertion of a double lumen port through the left femoral vein, rad... | cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter, |
4,828 | The patient was admitted after undergoing a drawn out process with a small bowel obstruction. | Cardiovascular / Pulmonary | Discharge Summary - Respiratory Failure | DISCHARGE DIAGNOSIS:,1. Respiratory failure improved.,2. Hypotension resolved.,3. Anemia of chronic disease stable.,4. Anasarca improving.,5. Protein malnourishment improving.,6. End-stage liver disease.,HISTORY AND HOSPITAL COURSE: ,The patient was admitted after undergoing a drawn out process with a small bowe... | cardiovascular / pulmonary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge, |
4,829 | Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine. Nondiagnostic dobutamine stress test. Normal nuclear myocardial perfusion scan. | Cardiovascular / Pulmonary | Dobutamine Stress Test | EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45. EKG, normal sinus rhythm. Post dobutamine increment dose, his peak hear... | cardiovascular / pulmonary, nuclear myocardial perfusion scan, dobutamine stress test, ejection fraction, myocardial perfusion, perfusion scan, dobutamine stress, stress test, myocardial, perfusion, nuclear, dobutamine, stress, |
4,830 | Patient had some cold symptoms, was treated as bronchitis with antibiotics. | Cardiovascular / Pulmonary | Discharge Summary | DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY... | cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, |
4,831 | A 3-year-old abrupt onset of cough and increased work of breathing. | Cardiovascular / Pulmonary | Discharge Summary - Respiratory Distress | ADMITTING DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,DISCHARGE DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,3. Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who ... | null |
4,832 | The patient is 14 months old, comes in with a chief complaint of difficulty breathing. | Cardiovascular / Pulmonary | Difficulty Breathing - ER Visit | HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get wors... | null |
4,833 | DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma, | Cardiovascular / Pulmonary | DDDR Permanent Pacemaker | PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old Africa... | null |
4,834 | Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators. | Cardiovascular / Pulmonary | Discharge Summary - COPD | PROCEDURES:,1. Chest x-ray on admission, no acute finding, no interval change.,2. CT angiography, negative for pulmonary arterial embolism.,3. Nuclear myocardial perfusion scan, abnormal. Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1. Chronic obstructive pulmonary di... | null |
4,835 | A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. | Cardiovascular / Pulmonary | Dilated Cardiomyopathy - Consult | REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed... | null |
4,836 | Direct laryngoscopy and bronchoscopy. | Cardiovascular / Pulmonary | Direct Laryngoscopy | PREOPERATIVE DIAGNOSIS:, Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:, General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table. General inhala... | cardiovascular / pulmonary, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis, |
4,837 | The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. | Cardiovascular / Pulmonary | CyberKnife Treatment - Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatm... | cardiovascular / pulmonary, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife, |
4,838 | A 10 years of age carries a diagnosis of cystic fibrosis | Cardiovascular / Pulmonary | Cystic Fibrosis | INTERVAL HISTORY:, ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit. He was accompanied by his adopted mother. He is attending the fourth grade and has not missed significant days for illness. He has a chronic cough that has been slightly in... | null |
4,839 | CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe. | Cardiovascular / Pulmonary | CT of Chest with Contrast | EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lob... | cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lo... |
4,840 | Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease. | Cardiovascular / Pulmonary | CVA - Discharge Summary | DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the lef... | cardiovascular / pulmonary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident |
4,841 | A 51-year-old male with chest pain and history of coronary artery disease. | Cardiovascular / Pulmonary | Coronary CT Angiography (CCTA) - 4 | COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath ... | null |
4,842 | 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. | Cardiovascular / Pulmonary | CT Angiography | 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 embol... | cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue, |
4,843 | 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. | Cardiovascular / Pulmonary | CT Angiography - 1 | 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 ... | cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism, |
4,844 | A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. | Cardiovascular / Pulmonary | CT Chest - 2 | CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. Right sided supraclavicular and lower anterior cervical adenopathy noted on physical e... | cardiovascular / pulmonary, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest, |
4,845 | Coronary Artery CTA with Calcium Scoring and Cardiac Function | Cardiovascular / Pulmonary | Coronary CT Angiography (CCTA) - 3 | EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did rece... | cardiovascular / pulmonary, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography, |
4,846 | CCTA with Cardiac Function/Calcium Scoring | Cardiovascular / Pulmonary | Coronary CT Angiography (CCTA) - 2 | CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG ... | cardiovascular / pulmonary, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, ... |
4,847 | CT chest with contrast. | Cardiovascular / Pulmonary | CT Chest - 1 | 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 line... | cardiovascular / pulmonary, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue, |
4,848 | Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal. | Cardiovascular / Pulmonary | Coronary Angiography | REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1. Selective coronary angiography.,2. Left heart catheterization with hemodynamics.,3. LV gram with power injection.,4. Right femoral artery angiogram.,5. Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient... | |
4,849 | Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. | Cardiovascular / Pulmonary | COPD & Pneumonia - SOAP | SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, she does not use oxygen at her independent assisted... | cardiovascular / pulmonary, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd |
4,850 | Common CT Chest template | Cardiovascular / Pulmonary | CT Chest | TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion. The aorta and great vessels are normal in caliber. The cen... | cardiovascular / pulmonary, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE |
4,851 | A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator. | Cardiovascular / Pulmonary | Coronary CT Angiography (CCTA) - 5 | COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Exami... | null |
4,852 | Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis. | Cardiovascular / Pulmonary | COPD & Bronchitis - Discharge Summary | DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypot... | cardiovascular / pulmonary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis, |
4,853 | Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography. | Cardiovascular / Pulmonary | Coronary Angiography & Abdominal Aortography | NAME OF PROCEDURE,1. Selective coronary angiography.,2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3. Abdominal aortography.,INDICATIONS: ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium ... | cardiovascular / pulmonary, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal, |
4,854 | A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. | Cardiovascular / Pulmonary | COPD - Discharge Summary | HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was adm... | cardiovascular / pulmonary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd, |
4,855 | CCTA with cardiac function and calcium scoring. | Cardiovascular / Pulmonary | Coronary CT Angiography (CCTA) - 1 | HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agen... | cardiovascular / pulmonary, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, cct... |
4,856 | The patient admitted with palpitations and presyncope. | Cardiovascular / Pulmonary | Consult - Palpitations & Presyncope | HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable patte... | cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart |
4,857 | Atrial fibrillation and shortness of breath. The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family histo... | Cardiovascular / Pulmonary | Consult - Atrial Fibrillation - 1 | REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman. The patient had shortness of breath over the last few days, progressively worse. Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopn... | null |
4,858 | Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. | Cardiovascular / Pulmonary | Consult - Atrial Fibrillation | REASON FOR CONSULTATION:, Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resi... | null |
4,859 | Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart f... | Cardiovascular / Pulmonary | Consult - Congestive Heart Failure | REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room sho... | null |
4,860 | A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed... | Cardiovascular / Pulmonary | Complex Cyanotic Congenital Heart Disease | HISTORY:, The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the righ... | null |
4,861 | Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom exc... | Cardiovascular / Pulmonary | Consult - Coronary Artery Disease | REASON FOR CONSULTATION:, Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subseq... | null |
4,862 | Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
| Cardiovascular / Pulmonary | Cineangiography - 1 | REASON FOR CATHETERIZATION:, ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Left ventriculogram.,4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncom... | cardiovascular / pulmonary, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis, |
4,863 | Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale. | Cardiovascular / Pulmonary | Coarctation of Aorta | HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicu... | cardiovascular / pulmonary, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen, |
4,864 | Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above. | Cardiovascular / Pulmonary | Consult - Abnormal EKG | REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient... | null |
4,865 | Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent. | Cardiovascular / Pulmonary | Cineangiography | PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angi... | cardiovascular / pulmonary, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad, |
4,866 | Left pleural effusion, parapneumonic, loculated. Left chest tube placement. | Cardiovascular / Pulmonary | Chest Tube Placement | PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patie... | cardiovascular / pulmonary, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest, |
4,867 | A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath. | Cardiovascular / Pulmonary | Chronic Atrial Fibrillation | REASON FOR VISIT:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a n... | null |
4,868 | Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh. | Cardiovascular / Pulmonary | Chest Wall Tumor Resection | PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruc... | cardiovascular / pulmonary, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung, |
4,869 | Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound. | Cardiovascular / Pulmonary | Chest Tube Removal | PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the... | cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest |
4,870 | Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized. | Cardiovascular / Pulmonary | Chest Pulmonary Angio | EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The prox... | cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio |
4,871 | A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina. | Cardiovascular / Pulmonary | Chest Pain & Respiratory Insufficiency | We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have ni... | cardiovascular / pulmonary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic |
4,872 | Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma. | Cardiovascular / Pulmonary | Chest Tube Insertion in ER | PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.... | cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion, |
4,873 | Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion. | Cardiovascular / Pulmonary | Chest PA & Lateral | EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, dif... | cardiovascular / pulmonary, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax, |
4,874 | Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain | Cardiovascular / Pulmonary | Chest Pain - Office Note | DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPIT... | cardiovascular / pulmonary, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test |
4,875 | Patient with palpitations and rcent worsening of chronic chest discomfort. | Cardiovascular / Pulmonary | Chest discomfort & palpitations - Consult. | CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyo... | null |
4,876 | Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. | Cardiovascular / Pulmonary | Chest Closure | PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected... | cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation |
4,877 | Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion. | Cardiovascular / Pulmonary | Chest Tube Insertion | PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.... | cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma |
4,878 | Chest pain, possible syncopal spells. She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long. | Cardiovascular / Pulmonary | Chest Pain - Cardiac Consult | REASON FOR REFERRAL:, Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy. Since then she just says "things have changed". She just does not want to go out anymore and just does not feel... | cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest, |
4,879 | Carotid Ultrasonic & Color Flow Imaging | Cardiovascular / Pulmonary | Carotid Doppler Report | Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID ... | cardiovascular / pulmonary, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery, |
4,880 | Left carotid endarterectomy with endovascular patch angioplasty. Critical left carotid stenosis. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted. | Cardiovascular / Pulmonary | Carotid Endarterectomy & Angioplasty. | PREOPERATIVE DIAGNOSIS:, Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:, Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:, Cervical block.,GROSS FINDINGS: ,The patient is a 57-year-old black female with chronic renal failur... | cardiovascular / pulmonary, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy |
4,881 | Right subclavian triple lumen central line placement | Cardiovascular / Pulmonary | Central Line Placement | PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,... | cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xyl... |
4,882 | Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery. | Cardiovascular / Pulmonary | Carotid & Cerebral Arteriograms | EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measu... | cardiovascular / pulmonary, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire, |
4,883 | Insertion of central venous line and arterial line and transesophageal echocardiography probe. | Cardiovascular / Pulmonary | Central Venous & Arterial Line | INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including ... | cardiovascular / pulmonary, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter |
4,884 | Central line insertion. Empyema thoracis and need for intravenous antibiotics. | Cardiovascular / Pulmonary | Central Line Insertion | PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopector... | cardiovascular / pulmonary, thoracis, intravenous, central line insertion, empyema, catheter, |
4,885 | Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries. | Cardiovascular / Pulmonary | Carotid Endarterectomy - 1 | PREOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,OPERATIONS,1. Right common carotid endarterectomy.,2. Right internal carotid endarterectomy.,3. Right external carotid endarterectomy.,4. Hem... | cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy |
4,886 | Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty. | Cardiovascular / Pulmonary | Carotid Endarterectomy | PREOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,PROCEDURE PERFORMED: ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE FINDINGS: , The common an... | cardiovascular / pulmonary, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy |
4,887 | Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation. | Cardiovascular / Pulmonary | Cardioversion - Direct Current - 1 | PROCEDURE: ,Direct-current cardioversion.,BRIEF HISTORY: ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and... | cardiovascular / pulmonary, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion, |
4,888 | Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. | Cardiovascular / Pulmonary | Cardioversion - Direct Current | PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing n... | cardiovascular / pulmonary, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion |
4,889 | Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times. | Cardiovascular / Pulmonary | Cardiomyopathy & Hypotension - Consult | REASON FOR CONSULTATION:, Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:, I am seeing the patient upon the request of Dr. X. The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admission... | null |
4,890 | Problem of essential hypertension. Symptoms that suggested intracranial pathology. | Cardiovascular / Pulmonary | Cardiology Progress Note | SUBJECTIVE:, The patient is a 78-year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She de... | cardiovascular / pulmonary, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial, |
4,891 | Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation. | Cardiovascular / Pulmonary | Cardioversion - Unsuccessful | REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of... | cardiovascular / pulmonary, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial, |
4,892 | Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease. | Cardiovascular / Pulmonary | Cardiovascular - Letter | Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation. This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity. He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intole... | cardiovascular / pulmonary, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy,... |
4,893 | Cardiology office visit sample note. | Cardiovascular / Pulmonary | Cardiology Office Visit - 2 | HISTORY OF PRESENT ILLNESS:, This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension. Patient has severe backache secondary to disc herniation. Patient has seen an orthopedic doctor and is scheduled for surgery. Patient also came to my office for s... | |
4,894 | Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction. | Cardiovascular / Pulmonary | Cardiology Progress Note - 1 | SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.,CHEST: There is prolonged expiration.,CARDIOVASCULAR: First and second heart sounds are ... | cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep, |
4,895 | Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation | Cardiovascular / Pulmonary | Cardioversion | HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion... | cardiovascular / pulmonary, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial, |
4,896 | Patient with chest pains, CAD, and cardiomyopathy. | Cardiovascular / Pulmonary | Cardiac Radionuclide Stress Test | INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:, Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart ra... | cardiovascular / pulmonary, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear |
4,897 | Follow up update on patient with left carotid angioplasty and stent placement. | Cardiovascular / Pulmonary | Cardiology - Letter | Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that sh... | cardiovascular / pulmonary, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample r... |
4,898 | Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning. | Cardiovascular / Pulmonary | Cardiac Transfer Summary | REASON FOR TRANSFER:, Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1. Coronary artery disease.,2. Chest pain.,3. History of diabetes.,4. History of hypertension.,5. History of obesity.,6. A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7. Deconditioning.,CONSULTATIONS: , C... | null |
4,899 | A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure. | Cardiovascular / Pulmonary | Cardio/Pulmo Discharge Summary | ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5... | cardiovascular / pulmonary, discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar... |
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