meta
dict | text
stringlengths 20
18.4k
|
|---|---|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2500
}
|
CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis. She was admitted to the hospital. The MRI showed only an old right basal ganglion infarct. She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP. The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms. Her vital capacities were normal during the hospitalization. Her chest x-ray was negative for any acute process. She was discharged to rehab from July 12, 2006 to July 20, 2006. She made some progress in which she notes that her walking is definitely better. However, she notes that she still has some problems with eye movement and her vision. This is possibly her main problem. She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:, Documented in the clinic note. The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Diabetes mellitus.,3. Stroke involving the right basal ganglion.,4. Guillain-Barre syndrome diagnosed in June of 2006.,5. Bilateral knee replacements.,6. Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:, Multiple family members have diabetes mellitus.,SOCIAL HISTORY:, The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs.,MEDICATIONS:, Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds. Pain scale 5/10. Please see the written note for details. General exam is benign other than mild obesity. On neuro examination, mental status is normal. Cranial nerves are significant for full visual fields and pupils are equal and reactive. However, extraocular movements are very limited. She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move. Face is symmetric. Sensation is intact. Tongue and uvula are in midline. Palate is elevated symmetrically. Shoulder shrug is strong. The patient's muscle exam shows normal bulk and tone throughout. She has no weakness of the left upper extremity. In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5. There is no drift or orbit. Reflexes are absent throughout. Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal. There is no dysmetria. Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:, As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. The patient has shown some improvement with IVIG and continues to show some gradual improvement. I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now. She is scheduled to see an ophthalmologist. I think it is reasonable for close followup of her visual symptoms progress. However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further. I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week. She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable. I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1. Guillain-Barre Miller-Fisher variant.,2. Hypertension.,3. Diabetes mellitus.,4. Stroke.,RECOMMENDATIONS:,1. The patient is to start taking aspirin 162 mg per day.,2. Followup with ophthalmology.,3. Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4. Followup by phone in three to four weeks.,5. Followup in this clinic in approximately two months' time.,6. Call for any questions or problems.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2501
}
|
PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:, None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma. She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X. It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. Consent was obtained. The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted. A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. She tolerated this procedure very well.surgery, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2502
}
|
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 to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner. Lidocaine 1% (20 mL) was administered to the area of the previous incision. A transverse incision was made through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. Using blunt dissection, pacemaker, and leads were removed from the pocket. Leads were disconnected from the pulse generator and interrogated. The pocket was washed with antibiotic impregnated saline. The new pulse generator was obtained and connected securely to the leads and placed back in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2. New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3. Right atrial lead, product # 4068, serial # ABCD1234.,4. Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 572 ohms. P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2. Right ventricular lead impedance 365 ohms. No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1. Successful dual chamber generator replacement.,2. No acute complications.,PLAN,1. She will be monitored for 3 hours and then dismissed home.,2. Resume all medications. Ex-home dismissal instructions.,3. Doxycycline 100 mg one p.o. twice daily for 7 days.,4. Wound check in 7-10 days.,5. Continue followup in device clinic.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2503
}
|
HISTORY OF PRESENT ILLNESS:, I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history. By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension. She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg. Other findings were not significantly changed including pericardial effusion description. She has a history of longstanding hypertension. She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1. Norvasc 10 mg once a day.,2. Aspirin 81 mg once a day.,3. Colace 200 mg two at bedtime.,4. Labetalol 100 mg p.o. b.i.d.,5. Nephro-Vite one tablet p.o. q.a.m.,6. Dilantin 100 mg p.o. t.i.d.,7. Renagel 1600 mg p.o. t.i.d.,8. Sensipar 120 mg p.o. every day.,9. Sertraline 100 mg p.o. nightly.,10. Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM: ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%. Height is 5 feet 1 inch, weight 147 pounds. On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. HEENT shows the cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins are difficult to assess, but do not appear clinically distended. No carotid bruits. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. No rub, no gallop. PMI is nondisplaced. Abdomen: Soft, nondistended. CVA is benign. Extremities with no significant edema. Pulses appear grossly intact. She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one. Echocardiogram results as above. Chest x-ray shows mild pulmonary vascular congestion. BNP shows 3788. Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90. Troponin was 0.40 followed by 0.34. INR 1.03 on 05/18/07. White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report. One of the questions we were asked was whether the patient would be a candidate for Coumadin. Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year. I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1. Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin. Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3. Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade. I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification. I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4. Continue Norvasc for history of hypertension as well as labetalol.,5. The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6. Continue Dilantin for history of seizures.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2504
}
|
PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder. The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips. Several attempts at passing the cholangiocatheter into the ductotomy were made. Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct. After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography. The distal cystic duct was doubly clipped. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery. Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.surgery, intraoperative cholangiogram, cystic artery, laparoscopic cholecystectomy, cystic duct, gallbladder, tonsil, cholecystectomy, cholangiogram, abdomen, laparoscopic, cannula,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2505
}
|
PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:, Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria. He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts. Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor. He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic. He was placed in lithotomy position and prepped and draped in the usual fashion. Using the visual obturator, the resectoscope was then inserted per urethra into the bladder. The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice. Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion. Following completion of resection down to the base, the bladder was _______ free of tumor specimen. The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen. Hemostasis was assured with electrocautery. The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor. Following completion of the fulguration, there was good hemostasis. The remainder of the bladder was without evidence of significant abnormality. Both ureteral orifices were visualized and noted to drain freely of clear urine. The bladder was filled and the resectoscope was removed. A 22-French 3-way Foley catheter was inserted per urethra into the bladder. The balloon was inflated to 30 mL. The catheter with sterile continuous irrigation and was noted to drain clear irrigant. The patient was then removed from lithotomy position. He was in stable condition.surgery, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2506
}
|
PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones. The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A 0.035 glidewire was placed in the left system. Using graspers, left-sided stent was removed. A semirigid ureteroscopy was done. A stone was visualized in the mid to upper ureter. Using laser, the stone was broken into 5 to 6 small pieces. Using basket extraction, all the pieces were removed. Ureteroscopy all the way up to the UPJ was done, which was negative. There were no further stones. Using pyelograms, the rest of the system appeared normal. The entire ureter on the left side was open and patent. There were no further stones. Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. Over the 0.035 glidewire, a 26 double-J stent was placed. There was a nice curl in the kidney and one in the bladder. The patient tolerated the procedure well. Please note that the string was kept in place and the patient was to remove the stent the next day. The patient's family was instructed how to do so. The patient had antibiotics and pain medications at home. The patient was brought to recovery room in a stable condition.urology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2507
}
|
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 proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1. Again demonstrated is a large right chest wall mass.,2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. See above regarding other findings.radiology, 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
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2508
}
|
CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2509
}
|
CHIEF COMPLAINT:, Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. Rates her pain in her knee as a 10/10. She does alternate ice and heat. She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1. PENICILLIN.,2. KEFLEX.,3. BACTRIM.,4. SULFA.,5. ACE BANDAGES.,MEDICATIONS,1. Toprol.,2. Xanax.,3. Advair.,4. Ventolin.,5. Tylenol No. 3.,6. Advil.,REVIEW OF SYSTEMS:, Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first. Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL: This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect. She is well developed, well nourished, appears her stated age.,EXTREMITIES: Orthopedic evaluation of the left knee reveals there to be well-healed portholes. She does have some medial joint line swelling. Negative ballottement. She has significant pain to palpation of the medial joint line, none of the lateral joint line. She has no pain to palpation on the popliteal fossa. Range of motion is approximately -5 degrees to 95 degrees of flexion. It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. She has a click with McMurray. Negative anterior-posterior drawer. No varus or valgus instability noted. Positive patellar grind test. Calf is soft and nontender. Gait is stable and antalgic on the left.,ASSESSMENT,1. Osteochondral defect, torn meniscus, left knee.,2. Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee. I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction. She questions whether she needs a total knee; I don't believe she needs total knee replacement. She may, however, at some point need an arthroscopy. I have encouraged her to start formal physical therapy and a home exercise program. Will use ice or heat p.r.n. I have given her refills on Tylenol No. 3, Flector patch, and Relafen not to be taken with any other anti-inflammatory. She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily. She will follow up in our office in four weeks. If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy. The patient shows a good understanding of this treatment plan and agrees.orthopedic, medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2510
}
|
FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed.neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2511
}
|
EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.podiatry, ankle joint, bone, mri, ankle
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2512
}
|
PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. The preparation was poor, but mucosa was visible after lavage and suction. Small lesions might have been missed in certain places, but no large lesions are likely to have been missed. The mucosa was normal, was visualized. In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing. Biopsies were taken from the rectal wall to look for microscopic changes. The anal sphincter was considerably relaxed, with no tone and a gaping opening. The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum. No contraindications to consideration of a repair of the prolapse.surgery, olympus, colonoscope, bowel habits, colonic mucosa, colonic, rectum, rectal, cecum, mucosa, colonoscopy,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2513
}
|
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.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain. Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis. She was brought to endoscopy suite #4 and informed consent was obtained. ,PROCEDURE DETAILS: ,The patient was placed in the supine position and intubated by the Anesthesia Service. Intravenous sedation was given as per Anesthesia. The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea. The right mainstem bronchus was examined. The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted. Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot. Tumor completely occluded both segments of the right middle lobe. Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions. Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus. Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions. The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions. There were some secretions noted throughout the left lung. The scope was retracted and passed again to the right mainstem bronchus. The area of the right middle lobe was reexamined. The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation. It did not appear as if a scope or cannula could be passed distal to the tumor. Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained. The area was examined for approximately one minute for assurance of adequate hemostasis. The scope was then retracted and the patient was sent to the recovery room in stable condition. She will be extubated as per the Anesthesia Service. Cytology and cultures were not sent due to the patient's known diagnosis. Further recommendations are pending at this time.surgery, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2514
}
|
PAST MEDICAL CONDITION:, None.,ALLERGIES:, None.,CURRENT MEDICATION:, Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:, The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:, The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bending to the right was decreased. Side bending to the left was within normal limits. Rotation and extension to the right side was causing increasing pain. Extension and side bending to the left was within normal limits without significant pain on the left side. While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°. There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. In supine position, straight leg was negative in the LLE and also negative on the RLE. Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. Medial hamstring reflex was 2+/4 on both hamstrings as well. On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:, I had the opportunity to review Dr. XYZ's medical records. Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December. Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal. The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:, The patient has an impairment based on AMA Guides Fifth Edition and it is permanent. The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck. Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. The patient also has increase in back pain with lumbar flexion and rotational movement to the right side. With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. Therefore, the patient is assigned 8% impairment of the whole person. We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide. Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury. In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI. In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,orthopedic, rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2515
}
|
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: , Cardiology.,PROCEDURES:,1. Echocardiogram.,2. MRI of the brain.,3. Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details. In brief, the patient is a 64-year-old male with history of diabetes, who presented with 6 hours of chest pressure. He was brought in by a friend. The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion. He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed. His vital signs were stable on admission. He was ruled out for myocardial infarction with troponin x2. An echocardiogram showed concentric LVH with an EF of 62%. I had Cardiology come to see the patient, who reviewed the records from Fountain Valley. Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax. I performed an MRI, which showed a 1 cm lesion in the right parietal lobe. I was going to call Neurology at XYZ for evaluation. However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:, Stable.,DISCHARGE MEDICATIONS:,1. Aspirin 325 mg p.o. daily.,2. Lovenox 40 mg p.o. daily.,3. Regular Insulin sliding scale.,4. Novolin 70/30, 15 units b.i.d.,5. Metformin 500 mg p.o. daily.,6. Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2516
}
|
PREOPERATIVE DIAGNOSIS:, Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for. The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap. He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty. After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty. He had previously undergone a CT scan. Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed. We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant. He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis. The scalp was prepped and draped in the usual sterile fashion. A previous incision was reopened and the scalp flap was reflected forward. We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap. We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base. We did explore laterally and saw a little bit of the mesh on the lateral orbit. Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws. We had achieved good hemostasis. The wound was closed in multiple layers in usual fashion over a Blake drain. At the end of the procedure, all sponge and needle counts were correct. A sterile dressing was applied to the incision. The patient was transported to the recovery room in good condition after having tolerated the procedure well. I was personally present and scrubbed and performed/supervised all key portions.surgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2517
}
|
PREOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1. Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2. Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3. Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:, None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition. Informed consent was obtained from the patient. All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. Each of the areas was cleaned with a sterile alcohol swab. Planned excision site was marked with a marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions. The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. However, it is somewhat deeper than the standard seborrheic keratosis. The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus. It was excised with a defect 0.5 x 0.5 cm. It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. Sterile dressing was applied afterwards. The patient was discharged in stable condition. Postop care instructions reviewed in detail. She is scheduled with me in one week and we will make further recommendations at that time.dermatology, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2518
}
|
PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.surgery, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2519
}
|
REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:, Historical information was obtained from a review of available medical records and clinical interview with Ms. A. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop. Neurological evaluation with Dr. X confirmed left hemiparesis. Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness. These symptoms were thought to be due to a right middle cerebral artery stroke. She was transferred to the ICU for monitoring. Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA. On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA. At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane. She was discharged home with recommendations for outpatient physical therapy. She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke." Brain CT on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan. Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup. Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change. MRI could not be completed due to the patient's weight. She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted. She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty. During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications. She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning. When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness. She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at. Note also that she had some difficulty explaining exactly what her job involved. She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY: ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night. She reported that since her appointment with Dr. X, she has been using it "every other night." When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. She reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. She receives approximately two to five hours of sleep per night. Other current untreated risk factors include obesity and hypercholesterolemia. Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:, Ms. A denied drinking alcohol or using illicit drugs. She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree. She reported that she primarily obtained B's and C's in school. She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing. As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition. She is now living on her own. She has never driven. She reported that she continues to perform ADLs independently such as cooking and cleaning. She lost her husband in 2005 and has three adult daughters. She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation. She also reported number of other family members who had recently passed away. She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes.",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Testnan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2520
}
|
CHIEF COMPLAINT:, "I can’t walk as far as I used to.",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.,He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,PAST MEDICAL HISTORY :, Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,PAST SURGICAL HISTORY :, Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,FAMILY HISTORY:, The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.,SOCIAL HISTORY:, The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.,MEDICATIONS:,1. Spironolactone 25 mg po qd.,2. Digoxin 0.125 mg po qod.,3. Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.,4. Metolazone 10 mg po qd.,5. Captopril 25 mg po tid.,6. Torsemide 40 mg po qam and 20 mg po qpm.,7. Carvedilol 3.125 mg po bid.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.,PHYSICAL EXAM:,Temperature: 98.4 degrees Fahrenheit.,Blood pressure: 134/84.,Heart rate: 98 beats per minute.,Respiratory rate: 18 breaths per minute.,Pulse oximetry: 92% on 2L O 2 via nasal canula.,GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink.,NECK: The neck was supple with 15 cm of jugular venous distension.,HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI.,LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base.,ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.,EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes were present.,SKIN: Warm, no rashes, no lesions; no tattoos.,MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.,STUDIES:,CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline.,ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion.,HOSPITAL COURSE:, The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2521
}
|
SUBJECTIVE:, The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed by Dr. Kumar. Those issues are stable. She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:, She has an intolerance to Prevacid.,CURRENT MEDICATIONS:, Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:, Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:, She is married. A 76-year-old who used to smoke a pack a day and quit in 1985. She is retired.,REVIEW OF SYSTEMS:, Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:, Temperature is 97.5 degrees. Blood pressure is 168/70. Pulse is 88. Weight is 129 pounds.,GENERAL: She is an elderly 76-year-old in no acute distress.,HEENT: Atraumatic. Extraocular muscles were intact. Pupils equal, round and reactive to light and accommodation. Tympanic membranes are clear, dry and intact. Sinuses and throat are clear. Neck is soft, supple. No meningeal signs are present. No thyromegaly is present.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,ABDOMEN: Soft, nontender. Bowel sounds are positive. No organomegaly or peritoneal signs are present.,EXTREMITIES: Moving all extremities. Peripheral pulses are normal. No edema is present.,NEUROLOGIC: Alert and oriented. Cranial nerves II-XII grossly intact. Strength 5+/5 globally. Reflexes 2+/IV globally. Romberg is negative. There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS: Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK: Straight.,SKIN: Clear.,GENITALIA: Deferred as she has been followed by Dr. XYZ many times this year. She does have a history of some elevated cholesterol.,ASSESSMENT:,1. Hypertension, suboptimal control.,2. Hypothyroidism.,3. Arthritis.,4. Allergic rhinitis.,5. History of kidney stones.,6. Osteoporosis.,PLAN:,1. CBC, complete metabolic profile, UA for hypertension.,2. Chest x-ray for history of breast cancer.,3. DEXA scan, full body for osteoporosis.,4. Flex is up to date.,5. Pneumovax has been given in the last five years.,6. Lipid profile for elevated cholesterol.,7. Refill meds.,8. Follow up every three to six months for blood pressure check or sooner p.r.n. problems.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2522
}
|
PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side.,2. Interpretation of Radiograph.,ANESTHESIA: ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side. Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room. Monitors placed, including EKG, Pulse oximeter, and BP cuff. Patient had a pillow placed under the shoulder blades. The head and neck was allowed to fall back into hyperextension. The neck region was prepped and draped in sterile fashion with Betadine and alcohol. Four sterile towels were placed. The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally. A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially. The needle is advanced prudently through the tissues, avoiding the carotid artery laterally. The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy. Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand. No venous or arterial blood return is noted. No cerebral spinal fluid is noted. Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz. After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region. This was done with intermittent aspiration vigilantly verifying negative aspiration. The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade. This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion. The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution. Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site. Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae. Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion. ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side. Four lesions were carried out.surgery, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2523
}
|
SUBJECTIVE:, A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago. Also, I cleaned out his maxillary sinuses. Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue. The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening. He finished up his Augmentin, by a day or two later he was off the Lortab. Mom has not noticed any unusual voice change. No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce. He has not had any nasal discharge or ever had any bleeding. He seems to be breathing better.,OBJECTIVE:, Exam looks good. The pharynx is well healed. Tongue mobility is normal. Voice sounds clear. Nasal passages reveal no discharge or crusting.,RECOMMENDATION:, I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive. He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth. It is okay to chew gum and it is okay to eat crunchy foods such as potato chips. The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well. There are no other restrictions or limitations. I told Mom, I had written to Dr. XYZ to let her know of the findings. The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed. He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.ent - otolaryngology, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2524
}
|
SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper. Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:, The patient and her daughter completed both days of diabetes education in a group setting. Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician. Fasting blood sugars are 127, 80, and 80. Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63. Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109. Assessment of her knowledge is completed at the end of the counseling session. She demonstrated increased knowledge in all areas and had no further questions. She also completed an evaluation of the class.,The patient's feet were examined during the education session. She had flat feet bilaterally. Skin color was pink, temperature warm. Pedal pulses 2+. Her right second and third toes lay on each other. Also, the same on her left foot. However, there was no skin breakdown. She had large bunions, medial aspect of the ball of both feet. She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care. First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels. Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control. Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control. Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:, Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness. She is to followup with Dr. XYZ for possible reduction in her insulin doses.consult - history and phy., dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2525
}
|
CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of "startle response (myoclonic movement of the shoulders)" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.neurology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2526
}
|
REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:, This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:, She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:, Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:, Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.,CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.,CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.,EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.,CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2. Possible small old myocardial infarction.,3. Hypertension with hypertensive cardiovascular disease.,4. Non-insulin-dependent diabetes mellitus.,5. Moderate obesity.,6. Hyperlipidemia.,7. Chronic non-pitting leg edema.,8. Arthritis.,9. GERD and positive history of peptic ulcer disease.,CONCLUSION:,1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3. Lower left quadrant pain, which could be due to diverticulosis.,4. Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2527
}
|
HISTORY: ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study. The patient stated that the results of that modified revealed aspiration with thin liquids only. He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips. Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow. Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid. Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow. The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule. The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids. The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food. The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling. Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation. The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid. No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1. The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2. The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3. The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4. The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient. I look forward to working with him in the outpatient setting to improve his swallowing function and safety. Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.gastroenterology, oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2528
}
|
IDENTIFYING DATA: ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests. He has had suicidal ideation, but this is currently in remission. Furthermore, he continues to have hopeless thoughts and crying spells. Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee. Due to this event, Mr. T was fired. It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months. Mr. T stated that work was his entire life and he based his entire identity on his work ethic. It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:, There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time. Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:, Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders. He denied any suicide attempts, or profound suicidal or homicidal ideation. Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:, Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years. No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth. Originally, he was raised by both parents, but they separated at an early age. When he was about seven years old, he was raised by his mother and stepfather. He did not sustain a relationship with his biological father from that time on. He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old. He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company. He then became a homemaker while his wife worked for Chrysler for approximately two years. Mr. T was married for eleven years, and divorced in 1993. He has a son who is currently 20 years old. After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam: Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense. At times he showed some involuntary movements that would be more akin to a resting tremor. There was no psychomotor retardation, but there was some mild psychomotor excitement. His speech was clear, concise, but pressured. His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger. There was no evidence of euphoria or diurnal mood variation. His affective expression was restricted range, but there was no evidence of lability. At times, his affective tone and facial expressions were inappropriate to the interview. There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations. There was no evidence of illusions, depersonalizations, or derealizations. Mr. T presented with a sequential and goal directed stream of thought. There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking. There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts. There was evidence of concreteness for similarities and proverbs. His intelligence was average. His concentration was mildly impaired, and there was no evidence of distractibility. He was oriented to time, place, person and situation. There was no evidence of clouded consciousness or dissociation. His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence. There was a moderate preoccupation with his physical health pertaining to his headaches. His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans. Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem. His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments. He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation. His credibility seemed good. There was no evidence for potential self-injury, suicide, or violence. The reliability and completeness of information was very good, and there were no barriers to communication. The information gathered was based on the patient's self-report and objective testing and observation. His attitude toward the examiner was neutral and his attitude toward the examination process was neutral. There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy. At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment. Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year. As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning. Furthermore, it only appears logical that this would precipitate a major depressive episode.ime-qme-work comp etc., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2529
}
|
CHIEF COMPLAINT: , Nausea and feeling faint.,HPI: ,The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today, she complains of some nausea. She feels weak. No other specific complaints.,REVIEW OF SYSTEMS: ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS: ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY: ,COPD and hypertension.,HABITS: ,Tobacco use, averages two cigarettes per day. Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY: ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2, pulse is 105, respirations 20, and BP 137/80. GENERAL: A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated. SKIN: Warm, dry, and good color. EYES: EOMI. PERRL. MOUTH: Clear. Mucous membranes moist. NECK: Supple. No JVD. LUNGS: Reveal faint expiratory wheeze heard in the posterior lung fields. HEART: Slightly tachycardic without murmur. ABDOMEN: Soft, positive bowel sounds, and nontender. No rebound or guarding is appreciated. BACK: No CVA tenderness. EXTREMITIES: Moves all four extremities. No pretibial edema. NEURO: Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils. Hemoglobin 10.7 and hematocrit 31.2 both are decreased. Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2. Amylase and lipase both normal. Clean catch urinalysis is unremarkable. Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7. It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD. Monitor indicates sinus tachycardia at rate 103. No ectopy.,ED COURSE: ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse. The patient was given albuterol unit dose small volume nebulizer treatment. Repeat lung exam reveals resolution of expiratory wheezing. The patient later had normal saline lock started by the nurse. She was given IV fluids of normal saline 1L wide open over approximately one hour. She was able to void urine indicating that she is well hydrated. Rectal examination was performed with female nurse in attendance. Good sphincter tone. No masses. The rectal secretions were heme negative. The patient was reassessed. She feels slightly better. Monitor now shows normal sinus rhythm, rate 81, no ectopy. Blood pressure is 136/66. The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history. Laboratory evaluation today indicates the following problems, anemia and hyponatremia. This could contribute the patient's feelings of tiredness and not feeling well. There is no evidence of rectal bleeding at this time. The patient was advised that she needs to follow up with Dr. X to further investigate these problems. The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1. Acute tiredness.,2. Anemia of unknown etiology.,3. Acute hyponatremia.,PLAN: ,The patient is advised to put salt on her food for the next week. Should be given discharge instruction sheet for anemia. Recommend follow up with personal physician, Dr. X in two to three days for recheck. Return to ED sooner if condition changes or worsen anyway. Discharged in stable condition.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2530
}
|
CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.orthopedic, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2531
}
|
EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.,FINDINGS: ,There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.,IMPRESSION: ,No acute intracranial process.radiology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2532
}
|
REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night. Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. On weekends, he might sleep until 8 to 9 a.m. On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP. He denies much tossing and turning and does not awaken with the sheets in disarray. He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore. He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina. He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS: ,Vital signs: Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories: The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea. I have recommended the patient continue CPAP indefinitely. He will be sending me his smart card for downloading to determine his CPAP usage pattern. In addition, he will continue efforts to maintain his weight at current levels or below. Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea. I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction. He will be returning for routine followup in 6 months.soap / chart / progress notes, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2533
}
|
CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid. It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1. Red, irritated eye.,2. Some burning and/or scratchy feeling.,3. There may be a purulent (pus) or a mucous type discharge.,HOW IS IT TREATED?,It depends on what caused the Pink Eye. It may or may not need medication for treatment. If medication is given, follow the directions on the label.,TO PREVENT THE SPREAD OF THE INFECTION:,1. Wash hands thoroughly before you use the medicine in your eyes. After using the medicine in your eyes. Every time you touch your eyes or face.,2. Wash any clothing touched by infected eyes.,Clothes,Towels,Pillowcases,3. Do not share make-up. If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.,4. Do not touch the infected eye because the infection will spread to the good eye. IMPORTANT!!!,5. Pink Eye Spreads Very Easily!ophthalmology, eyelid, infected eyes, pink eye, conjunctivitis, eyes, infection, eye
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2534
}
|
DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2535
}
|
FINAL DIAGNOSES:,1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2. Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful. More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty. Blood loss was about 125 cc. Postop x-ray showed good alignment and positioning of the cages, plate, and screws. After surgery, he was able to slowly increase his activity level with assistance from physical therapy. He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. He also had some nausea with the PCA. He had a low-grade fever to 100.2 and was started on incentive spirometry. Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home. He has been counseled regarding wound care and has received a neck sheet for instruction. He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems.neurosurgery, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2536
}
|
An orbital block was done. An infraorbital block was also performed with a 25 gauge needle. A skin muscle flap was elevated by sharp dissection down to the orbital rim area. The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp. The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit. This was done in three compartments, the middle, medial and lateral compartments. Fat was removed from all three compartments. Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal. The patient tolerated the procedure well.ophthalmology, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clampingNOTE,: 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 reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2537
}
|
FINAL DIAGNOSES:,1. Cardiac arrest.,2. Severe congestive heart failure.,3. Acute on chronic respiratory failure.,4. Osteoporosis.,5. Depression.,HISTORY OF PRESENT ILLNESS: , This 92-year-old lady with history of depression and chronic low back pain, osteoporosis, and congestive heart failure, was diagnosed having pneumonia approximately for at least 10 days prior to admission. In the ER, she was given oral antibiotics. She also saw me few days before admission coming for a followup. She was doing fairly well. She was thought to have congestive heart failure and she was advised to continue with her diuretics. For the last few days, the patient started to have anorexia, she did not eat well, and she did not drink well. Her family could not take care of her. So, she was brought to the emergency room, where she was found to have rapid heart rate with a sinus tachycardia around 112 to 130s. The ________ was found to be dry. She was given 1 L of IV fluids and she was subsequently admitted in the hospital for further management.,COURSE IN THE HOSPITAL: , The patient stayed in the telemetry. The patient had significant shortness of breath secondary to congestive heart failure with bilateral basilar crackles. She was continued on IV antibiotics and general IV hydration was started initially because of low blood pressure and low perfusion status. On subsequently improved and stopped and Lasix was started; Dr. X, cardiologist was also placed. The patient's family wanted her to be a DNR and DNI. They were allowing us to treat her aggressively medically for pneumonia and congestive heart failure. However, the patient became extremely weak, mostly unresponsive. At this time, the patient's family wanted a Hospice consult, which was requested. By the time the Hospice could evaluate her, the patient's condition got deteriorated, she went into more bradycardiac and hypertension and subsequently expired. Please see the hospital notes for complete details.discharge summary, bradycardiac, hypertension, hospice, congestive heart failure, cardiac arrest, respiratory failure,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2538
}
|
HISTORY:, The patient was in the intensive care unit setting; he was intubated and sedated. The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated. He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output. His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia. Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1. Pancreatitis.,2. Poison ivy. The patient has recently been on oral steroids.,3. Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour. The patient was initially on dopamine, which has now been discontinued. The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:, Vitals, emergency room presentation, the blood pressure was 82/45. His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2. The patient has had minimal urine output since admission. HEENT, the patient is intubated at the moment. Neck examination, no overt lymph node enlargement. No jugular venous distention. Lungs examination is benign in terms of crackles. The patient has some harsh breath sounds secondary to being intubated. CVS, S1 and S2 are fairly regular at the moment. There is no pericardial rub. Abdominal examination, obese, but benign. Extremity examination reveals no lower extremity edema. CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2. The patient's BUN and creatinine yesterday were 23 and 2.1 respectively. H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning. The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55. Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1. Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2. He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis. The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight. Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2. Hypotension, which is significant and is related to his sepsis. Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3. Acidosis, which is again secondary to his renal failure. The patient was administered intravenous bicarbonate as mentioned above. Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4. Pancreatitis, which has been managed by his gastroenterologist.,5. Sepsis, the patient is on broad-spectrum antibiotic therapy.,6. Hypercalcemia. The patient has been given calcium chloride. We will need to watch for rebound hypercalcemia.,7. Hypoalbuminemia.,8. Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration.nephrology, intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, conventional hemodialysis, continuous venovenous, venovenous hemodiafiltration, blood pressure, venovenous, bicarbonate, sepsis,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2539
}
|
PROCEDURE:, Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:, The patient was prepped after informed consent was given of risk of infection and foreign body reaction. The area was marked by the patient and then prepped. The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through. A small ball was placed over the end of the ring. This terminated the procedure.,The patient tolerated the procedure well. Postop instructions were given regarding maintenance. Patient left the office in satisfactory condition.surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2540
}
|
DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:, Colonoscopy.,FINDINGS:, Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood. Dr. Y Miller saw him in consultation and recommended a colonoscopy. A bowel prep was done. H&Hs were stable. His most recent H&H was 38.6/13.2 that was this morning. His H&H at admission was 41/14.3. The patient had the bowel prep that revealed no significant bleeding. His vital signs are stable. He is continuing on his usual medications of Imdur, metoprolol, and Synthroid. His Plavix is discontinued. He is given IV Protonix. I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8. Chemistry panel was unremarkable. The patient was given a regular diet after his colonoscopy today. He tolerated it well and is being discharged home. He will be followed closely as an outpatient. He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission. He will hold his Plavix for now. They will call me for further dark stools and will avoid Pepto-Bismol. They will follow up in the office on Thursday.gastroenterology, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2541
}
|
HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.,PAST MEDICAL HISTORY:, The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:, She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL: The patient is an elderly frail white female in no distress. LUNGS: Clear. HEART: Sounds are regular. ABDOMEN: She has a protuberant abdomen. She has tenderness to palpation in the lumbosacral area. Sciatic notch tenderness is not present. Straight leg raise testing evokes back pain. NEUROLOGICAL: She is awake, alert, and oriented. Speech is intact. Comprehension is normal. Strength is intact in the upper extremities. She has giveaway strength in the lower extremities. Reflexes are diminished at the knees and ankles. Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture. A CT scan has shown some healing of this fracture. She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain. She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments. At this point, I believe the patient is a good candidate for L5 kyphoplasty. I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery. Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed. The patient understands the issues involved. She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.orthopedic, leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2542
}
|
TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis. The vertebral body heights and disc spaces are maintained. The central canal is patent. The pedicles and posterior elements are intact. The paravertebral soft tissues are within normal limits. The atlanto-dens interval and the dens are intact. The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.radiology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2543
}
|
MALE PHYSICAL EXAMINATION,HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate.,NECK: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no jugular venous distention.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm without S3, S4. No murmurs or rubs are appreciated.,ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. No masses, hepatomegaly or splenomegaly are appreciated.,GU: Normal **circumcised male. No discharge or hernias. No testicular masses.,RECTAL EXAM: Normal rectal tone. Prostate is smooth and not enlarged. Stool is Hemoccult negative.,EXTREMITIES: Reveal no clubbing, cyanosis, or edema. Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM: Reveals no tenosynovitis.,NEUROLOGIC: Cranial nerves II through XII are grossly intact. Motor strength is 5/5 and equal in all four extremities. Deep tendon reflexes are +2/4 and equal bilaterally. Patient is alert and oriented times 3.,PSYCHIATRIC: Grossly normal.,DERMATOLOGIC: No lesions or rashes.consult - history and phy., male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2544
}
|
PROCEDURE:, Cervical epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the sitting position. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between C7-T1 ________. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted. After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected. Neosporin and band-aid were applied over the site. The patient discharged to recovery room in stable condition.pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, injection,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2545
}
|
SUBJECTIVE:, Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:, Asthma and allergies.,FAMILY HISTORY: ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General: The patient is an 11-year-old female. Alert and cooperative. No acute distress.,Neck: Supple without adenopathy.,HEENT: Ear canals clear. TMs, bilaterally, gray in color and good light reflex. Oropharynx is pink and moist. No erythema or exudates. She has postnasal discharge. Nares are swollen and red. Purulent discharge in the posterior turbinates. Both maxillary sinuses are tender. She has some mild tenderness in the left frontal sinus. Eyes are puffy and she has dark circles.,Chest: Respirations are regular and nonlabored.,Lungs: Clear to auscultation throughout.,Heart: Regular rhythm without murmur.,Skin: Warm, dry and pink. Moist mucous membranes. Red, lacey rash from the wrists to the elbows, both sides. It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:, Fifth disease with sinusitis.,PLAN:, Omnicef 300 mg daily for 10 days. May use some Zyrtec for the itching. Samples are given.general medicine, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2546
}
|
PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling. He has gastroesophageal reflux disease.,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago. ,SOCIAL HISTORY:, He is currently single. He has about ten drinks a year. He had smoked significantly up until several months ago. He now smokes less than three cigarettes a day.,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes. Denies obesity and hypertension in other family members.,CURRENT MEDICATIONS:, None.,ALLERGIES:, He is allergic to Penicillin.,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program. He had a poor experience with the Greenwich program. Eating history, he is not an emotional eater. Does not like sweets. He likes big portions and carbohydrates. He likes chicken and not steak. He currently weighs 312 pounds. Ideal body weight would be 170 pounds. He is 142 pounds overweight. If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin. Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:, He is alert and oriented x 3. Cranial nerves II-XII are intact. Afebrile. Vital Signs are stable.bariatrics, laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2547
}
|
PHYSICAL EXAMINATION,GENERAL: ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS: ,The ear canals are patent without edema, exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge. No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard.,NECK: , No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline.,CHEST: , Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally. No rales, rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm. No murmur. No S3, S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge. Vaginal vault is without discharge. Cervix is of normal color without lesion. The os is closed. There is no bleeding noted. Uterus is noted to be of normal size and nontender. No cervical motion tenderness is seen. No masses are palpated. The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted.,SKIN: , No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen.,PSYCHIATRIC: ,The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2548
}
|
PREOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Anterior cervical fusion, C5-C6.,3. Anterior cervical instrumentation, C5-C6.,4. Allograft C5-C6.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS:, None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months. Nonoperative measures failed to relieve her symptoms and surgical intervention was requested. We discussed reasonable risks, benefits, and alternatives of various treatment options. Continuation of nonoperative care versus the risks associated with surgery were discussed. She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery. Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite. General anesthetic was administered. The patient was placed in the supine position. All prominences and neurovascular structures were well accommodated. The patient was noted to have pulse in this position. Preoperative x-rays revealed appropriate levels for skin incision. Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed. The patient was then prepped and draped in sterile fashion. Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease. Subcutaneous tissue was dissected down to the level of the omohyoid which was transected. Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally. This was taken down to the prevertebral fascia which was bluntly split. Intraoperative x-ray was taken to ensure proper levels. Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures. Inferior spondylosis was removed with high-speed bur. A scalpel and curette was used to remove the disc. Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally. Disc herniation was removed from the right posterolateral aspect of the interspace. High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion. Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura. No further evidence of compression was identified. Hemostasis was achieved with thrombin-soaked Gelfoam. Interspace was then distracted with Caspar pin distractions set gently. Interspace was then gently retracted with the Caspar pin distraction set. An 8-mm allograft was deemed in appropriate fit. This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit. The graft was stable to pull-out forces. Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws. Plate and screws were then locked to the plate. Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft. Wounds were copiously irrigated with normal saline. Omohyoid was approximated with 3-0 Vicryl. Running 3-0 Vicryl was used to close the platysma. Subcuticular Monocryl and Steri-Strips were used to close the skin. A deep drain was placed prior to wound closure. The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition. There were no intraoperative complications. All needle and sponge counts were correct. Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.surgery, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2549
}
|
PREOPERATIVE DIAGNOSIS:, Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,SPECIMENS: , None.,FINDINGS: , Deep complex left forehead laceration.,HISTORY: , The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site. He was brought to the Emergency Room, where a CAT scan of the head and facial bumps was performed, which were negative.,Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision. The patient was allowed to ask all questions he wanted, and they were answered in a language he could understand. He wished to pursue surgery and signed the informed consent.,PROCEDURE: , The patient was placed in the supine position. The wound was copiously irrigated with normal saline on irrigating tip. After one liter of irrigation, the wound was prepped and draped in the usual sterile fashion. The incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used. We then reapproximated the wound in double-layered fashion with deep sutures of #5-0 Vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon. The wound came together very nicely. Tincture of Benzoin was placed. Steri-Strips were placed over the top and a small amount of bacitracin was placed over the Steri-Strips. The patient tolerated the procedure well with no complications.surgery, plastic closure, facial laceration, deep complex facial laceration, steri strips, closure, bleeding, sterile, sutures, forehead, wound, supraorbital, facial, laceration
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2550
}
|
PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.surgery, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2551
}
|
SUBJECTIVE:, The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flaring of her acne with small folliculitis lesions. The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also. She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc. The patient is married. She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:, She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:, Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:, The patient is well developed, appears stated age. Overall health is good. She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:, Acne with folliculitis.,TREATMENT:,1. Discussed condition and treatment with the patient.,2. Continue the amoxicillin 500 mg two at bedtime.,3. Add Septra DS every morning with extra water.,4. Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5. Referred to ABC clinic for an aesthetic consult. Return in two months for followup evaluation of her acne.soap / chart / progress notes, acne with folliculitis, tazorac cream, acne, dermatology, tazorac, cream, folliculitis,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2552
}
|
PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye. CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye. CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:, The patient had epiretinal membrane causing cystoid macular edema. Options were discussed with the patient stressing that the visual outcome was guarded. Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table. Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified. Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified. The fluid was run. Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock. Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety. There were no complications. DVT precautions were in place. I, as attending, was present in the entire case.surgery, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2553
}
|
HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN: ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.consult - history and phy., lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2554
}
|
GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline. Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:, The patient has normal and symmetric respiratory effort. Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender. Bowel sounds are active. No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL: ,The patient is ambulatory with normal and symmetric gait. There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions. Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:, Mental status, judgment and affect are grossly intact and normal for age.consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2555
}
|
CHIEF COMPLAINT:, This 26-year-old male presents today for a complete eye examination.,ALLERGIES:, Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:, Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:, Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:, Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils: Pupil exam reveals round and equally reactive to light and accommodation.,Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields: Confrontation VF exam reveals full to finger confrontation O.U.,IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving.,Keratometry:,OD: K1 35.875K2 35.875,OS: K1 35.875K2 41.875,Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.,Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.,Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens: Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping.,Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15.,REFRACTION:,Lenses - final:,OD: +0.50 +1.50 X 125 Prism 1.75,OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add: OD: +1.00 OS: +1.00,OU: Far VA 20/25,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Eye and vision exam normal.,PLAN:, Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2556
}
|
ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:, Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:, None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure. She tolerated without difficulty. She had her pain controlled with p.o. pain medicine. She was afebrile. She is tolerating liquid diet. It was felt that the patient is stable for discharge. She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs. We will check a UA and urine culture prior to discharge. I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain. Her labs were within normal limits. She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related. Her labs in terms of her bilirubin were within normal limits. Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed. They were 51 and 83 for the AST and ALT respectively. I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower. She needs to keep her wound clean and dry. She is not to engage in any heavy lifting greater than 10 pounds x2 weeks. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility. She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:, We will follow up on both urinalysis and cultures. She is instructed to follow up with Dr. X in 2 weeks. She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.discharge summary, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2557
}
|
EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition, oral ReadiCAT was given. Reformatted sagittal and coronal images were obtained.,DISCUSSION:, There are numerous subcentimeter nodules seen within the lung bases. The largest measures up to 6 mm. No hiatal hernia is identified. Consider chest CT for further evaluation of the pulmonary nodules. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits. No dilated loops of bowel. There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat. In addition, there is soft tissue stranding seen of the lower pelvis. In addition, the uterus is not identified. Correlate with history of recent surgery. There is no free fluid or lymphadenopathy seen within the abdomen or pelvis. The bladder is within normal limits for technique.,No acute bony abnormalities appreciated. No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1. Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2. Numerous subcentimeter nodules seen within the lung bases. Consider chest CT for further characterization.gastroenterology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2558
}
|
REASON FOR VISIT: ,Elevated PSA with nocturia and occasional daytime frequency.,HISTORY: , A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues. The patient has had history of an elevated PSA and PSA in 2004 was 5.5. In 2003, he had undergone a biopsy by Dr. X, which was negative for adenocarcinoma of the prostate. The patient has had PSAs as high as noted above. His PSAs have been as low as 1.6, but those were on Proscar. He otherwise appears to be doing reasonably well, off the Proscar, otherwise does have some irritative symptoms. This has been ongoing for greater than five years. No other associated symptoms or modifying factors. Severity is moderate. PSA relatively stable over time.,IMPRESSION: , Stable PSA over time, although he does have some irritative symptoms. After our discussion, it does appear that if he is not drinking close to going to bed, he notes that his nocturia has significantly decreased. At this juncture what I would like to do is to start with behavior modification. There were no other associated symptoms or modifying factors.,PLAN: , The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed. He already knows that this does decrease his nocturia. He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha-blocker to something of more efficacious.urology, daytime frequency, psa, irritative symptoms, elevated psa, frequency, nocturia
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2559
}
|
PREOPERATIVE DIAGNOSIS: ,Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,POSTOPERATIVE DIAGNOSIS: , Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,TITLE OF OPERATION: , Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 59-year-old white male, who had an initial occurrence of a transitional cell carcinoma 5 years back. He was found to have a new tumor last fall, and cystoscopy in November showed Ta papillary-appearing lesion inside the bladder neck anteriorly. The patient had coronary artery disease and required revascularization, which occurred at the end of December prior to the tumor resection. He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT.,FINDINGS: , Cystoscopy of the anterior and posterior urethra was within normal limits. From 12 o'clock to 4 o'clock inside the bladder neck, there was a papillary tumor with some associated blood clot. This was completely resected. There was an abnormal dysplastic area in the left lateral wall that was biopsied, and the remainder of the bladder mucosa appeared normal. The ureteral orifices were in the orthotopic location. Prostate was 15 g and benign on rectal examination, and there was no induration of the bladder.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite, and after adequate general laryngeal mask anesthesia obtained, placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion. He had been given oral ciprofloxacin for prophylaxis. Rectal bimanual examination was performed with the findings described. Cystourethroscopy was performed with a #23-French ACMI panendoscope and 70-degree lens with the findings described. A barbotage urine was obtained for cytology. The cystoscope was removed and a #24-French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced. Several biopsies were taken from the tumor and sent to the tumor bank. I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria. Because of the Ta appearance, I did not intentionally dissect deeper into the muscle. Complete hemostasis was obtained. All the chips were removed with an Ellik evacuator. Using the cold cup biopsy forceps, biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved. The irrigant was clear. At the conclusion of the procedure, the resectoscope was removed and a #24-French Foley catheter was placed for efflux of clear irrigant. The patient was then returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.urology, transitional cell carcinoma, urinary bladder, bladder tumor, cystoscopy, transurethral resection, acmi panendoscope, foley catheter, cold cup biopsy forceps, ta nx mx, cold cup biopsy, laryngeal mask, bladder neck, bladder, biopsy, tumor,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2560
}
|
PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED: ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:, This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. It appears to be right down to the bone. MRI shows findings suggestive of osteomyelitis. The patient is being brought to operating room for debridement of this ulcer. Procedure, indication, and risks were explained to the patient. Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped. Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer. This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base. The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone. The deeper portion of the excised tissue was also sent for tissue cultures. Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix. Sterile dressing was applied. The patient transferred to recovery room in stable condition.gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2561
}
|
PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:, Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. Preoperative antibiotics were given for prophylaxis against surgical infection. The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found. The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels. This was dissected back to the hernia opening. The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring. The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures. By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.surgery, cremasteric muscle, pubic tubercle, external oblique aponeurosis, inguinal herniorrhaphy, inguinal hernia, cord structures, penrose drain, bovie electrocautery, inguinal, herniorrhaphy, metzenbaum, bovie, electrocautery, cord, hernia
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2562
}
|
OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2563
}
|
SUBJECTIVE:, The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.,ALLERGIES: , None.,MEDICATIONS:, She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.,SOCIAL HISTORY:, She is a nonsmoker.,REVIEW OF SYSTEMS:, As noted above.,OBJECTIVE:,Vital Signs: Temperature: 98.2. Pulse: 64. Respirations: 16. Blood pressure: 110/56. Weight: 169.,General: Alert and oriented x 3. No acute distress noted.,Neck: No lymphadenopathy, thyromegaly, JVD or bruits.,Lungs: Clear to auscultation.,Heart: Regular rate and rhythm without murmur or gallops present.,Breasts: Exam performed with a female nurse present. The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. No breast tissue retraction noted in either the sitting or the supine position. Upon palpation there were no palpable lumps or bumps and no palpable discharge.,Musculoskeletal: She did have full range of motion of her shoulders. She did have tenderness upon palpation over the right bicipital tendon. There is no swelling, crepitus or discoloration noted.,MEDICAL DECISION MAKING: Most recent hemoglobin A1c was 5.6% back in October 2004. Most recent lipid checks were obtained back in July 2004. We have not had this checked since that time.,ASSESSMENT:,1. Type II diabetes mellitus.,2. Hypertension.,3. Right shoulder pain.,4. Hyperlipidemia.,PLAN:,1. She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.,2. We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.,3. I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.,4. She is going to follow up in the clinic in three months for a complete comprehensive examination. If any questions, concerns or problems arise between now and then she should let us know.
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2564
}
|
PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:, Breast mass, left.,PROCEDURE:, Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Preoperative antibiotic was given. The patient was prepped and draped in the usual fashion. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc. Hemostasis was achieved with the cautery. The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl. A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.obstetrics / gynecology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2565
}
|
PREOPERATIVE DIAGNOSIS:, Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:, Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY: ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy. Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy. Potential complications include but are not limited to,,1. Infection.,2. Bleeding.,3. Postoperative pain.,4. Herniation from the incision.,PROCEDURE IN DETAIL:, Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room. General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position. A left flank incision was made over the area of the twelfth rib. The subcutaneous space was opened by using the Bovie. The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie. The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered. Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified. The peritoneum was swept medially. The Finochietto retractor was then placed for exposure. The kidney was readily identified and was mobilized from outside Gerota's fascia. The ureter was dissected out easily and was separated with a vessel loop. The superior aspect of the kidney was mobilized from the superior attachment. The pedicle of the left kidney was completely dissected revealing the vein and the artery. The artery was a single artery and was dissected easily by using a right-angle clamp. A vessel loop was placed around the renal artery. The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney. The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor. Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor. Bulldog clamp was then placed on the renal artery. The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex. This was performed by using the blunted end of the scalpel. The tumor was removed easily. The argon beam coagulation device was then utilized to coagulate the base of the resection. The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture. The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through. Two horizontal mattress sutures were placed and were tied down. The Gerota's fascia was then also closed by using 2-0 Vicryl suture. The area of the kidney at the base was covered with Surgicel prior to tying the sutures. The bulldog clamp was removed and perfect hemostasis was evident. There was no evidence of violation into the calyceal system. A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision. The drain was anchored by using silk sutures. The flank fascial layers were closed in three separate layers in the more medial aspect. The lateral posterior aspect was closed in two separate layers using Vicryl sutures. The skin was finally reapproximated by using metallic clips. The patient tolerated the procedure well.nephrology, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2566
}
|
CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a local ER and HCT revealed a right supraorbital fracture, right SDH and left SAH. Spine X-rays revealed a T12 vertebral body fracture. There were retinal hemorrhages, OU. She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic/neurosurgical care.,MEDS:, (on transfer): Dilantin, Zantac, Proventil MDI, Tylenol.,PMH:, 1)pyelonephritis, 2) multiple STD's, 3) Polysubstance Abuse (ETOH, MJ, Amphetamine), 4)G5P4.,FHX:, unknown.,SHX: ,polysubstance abuse. smoked 1 pack per day for 15years.,EXAM: ,BP127/97, HR83, RR25, 37.2C,MS: Minimal to no spontaneous speech. Unresponsive to verbal commands. Lethargic and somnolent. Groaned "yes" inappropriately.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. VFFTT. Retinal hemorrhages, OU. EOM difficult to assess. Facial movement appeared symmetric. Tongue midline. Corneal and gag responses were intact.,MOTOR: no spontaneous movement. withdrew extremities to noxious stimulation (e.g. deep nail bed pressure).,Sensory: withdrew to noxious stimuli.,Coord/Station/Gait: not tested.,Reflexes: 2+/2+ BUE. 2/2 BLE. Babinski signs were present, bilaterally.,HEENT: Periorbital and upper lid ecchymoses about the right eye. Scleral hemorrhage, OD.,GEN EXAM: mild bruising of the extremities.,COURSE: ,2/27/95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli. These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage.,2/28/95 brain MRI revealed: 1)a small right-sided SDH, 2) Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic/vascular injury, 3)abnormal signal within the right basal ganglia/caudate nucleus consistent with ischemia, 4) abnormal signal in the uncal portion of the right frontal lobe consistent with contusion, 5) small parenchymal hemorrhage in the inferior anterior right temporal lobe, and 6) opacification of the right maxillary sinus.,EEG, 2/28/95, was abnormal with occasional sharp transients in the left temporal region, and irregular (more or less continuous) right greater than left delta slow waves and decreased background activity in the right hemisphere: the findings were consistent with focal pathology on the right, seizure tendency in the left temporal region, and bilateral cerebral dysfunction. By the time of discharge, 4/17/95, she was verbalizing one or two words and required assistance with feeding and ambulation. She could not function independently.consult - history and phy., closed head injury, axonal injury, vascular injury, substantia nigra, subdural hematoma, subarachnoid hemorrhage, vascular, ischemic, injury, occipital lobe, retinal hemorrhages, temporal region, axonal, hemorrhages, hemorrhage,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2567
}
|
EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM: ,1. Atrial fibrillation with rapid ventricular rate.,2. Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl. Following this, transesophageal probe was placed in the esophagus. Transesophageal views of the heart were then obtained.,FINDINGS:,1. Left ventricle is of normal size. Overall LV systolic function is preserved. Estimated ejection fraction is 60% to 65%. No wall motion abnormalities are noted.,2. Left atrium is dilated.,3. Left atrial appendage is free of clots.,4. Right atrium is of normal size.,5. Right ventricle is of normal size.,6. Mitral valve shows evidence of mild MAC.,7. Aortic valve is sclerotic without significant restriction of leaflet motion.,8. Tricuspid valve appears normal.,9. Pulmonic valve appears normal.,10. Pacer wires are noted in the right atrium and in the right ventricle.,11. Doppler interrogation of moderate mitral regurgitation is present.,12. Mild-to-moderate AI is seen.,13. No significant TR is noted.,14. No significant TI is noted.,15. No pericardial disease seen.,IMPRESSION:,1. Preserved left ventricular systolic function.,2. Dilated left atrium.,3. Moderate mitral regurgitation.,4. Aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5. Left atrial appendage is free of clots.,Following these, direct current cardioversion was performed. Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm. The patient remained in atrial fibrillation.,PLAN: , Plan will be to continue medical therapy. We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2568
}
|
TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are within normal limits. ,IMPRESSION: , No acute abnormalities.neurology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2569
}
|
PRIMARY DIAGNOSIS:, Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:, Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:, Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed. Esophagus was visualized. The quarter was visualized at the aortic knob, was removed with grasper. Estimated blood loss 0. Intravenous fluids during time of procedure 100 mL. No tissues. No complications. The patient tolerated the procedure well. Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure. The patient was transferred from OR to PACU in stable condition.surgery, esophagus, foreign body, esophagoscopy, esophageal,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2570
}
|
GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2571
}
|
PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:, None.,FINDINGS:, Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:, The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion. This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube. The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:, The patient was given additional fentanyl, Versed as well as paralytics for the procedure. Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina. There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. Extensive secretions extended down into the secondary airways. This was lavaged with saline and suctioned dry. There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator. Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2. The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2572
}
|
HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.consult - history and phy., mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2573
}
|
CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag." According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Question of hypertension.,3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4. Status post cholecystectomy.,7. Status post unknown foot surgery.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY: ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact.,NECK: Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR: Regular rate and rhythm.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN: ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2574
}
|
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 intolerance. Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND. He is known to have a mother with coronary heart disease. He has never been a smoker. He has never had a syncopal episode, MI, or CVA. He had his gallbladder removed. No bleeding tendencies. No history of DVT or pulmonary embolism. The patient is retired, rarely consumes alcohol and consumes coffee moderately. He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep. He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches. His heart rate was 98 beats per minute and regular. His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position. He is in no distress. Venous pressure is normal. Carotid pulsations are normal without bruits. The lungs are clear. Cardiac exam was normal. The abdomen was obese and organomegaly was not palpated. There were no pulsatile masses or bruits. The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character. There was no peripheral edema. ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl. Renal function was normal. His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL. His sodium was a little bit increased. His A1c hemoglobin was increased. He had a spirometry, which was reported as normal. ,He had a resting electrocardiogram on December 20, 2002, which was also normal. He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate. There were no symptoms or ischemia by EKG. There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease. I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation. He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings. ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification. I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient. He also should start aggressively losing weight. I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis. ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix. The patient is allergic to aspirin. I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes. Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should. This, however, I will leave entirely up to you to decide. If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.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, heart, atherosclerosis, diabetes, coronary, aspirin
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2575
}
|
EXAM: , MRI of lumbar spine without contrast.,HISTORY:, A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1: Central canal, neural foramina are patent.,L4-L5: Central canal, neural foramina are patent.,L3-L4: Central canal, neural foramen is patent.,L2-L3: Central canal, neural foramina are patent.,L1-L2: Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.orthopedic, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2576
}
|
PREOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1. Arthroscopic lateral meniscoplasty.,2. Patellar shaving of the right knee.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:, Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE: ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position. Department of Anesthesia administered general anesthetic to the patient. All bony prominences were well padded at this time. The right lower extremity was then properly positioned in a Johnson knee holder. At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions. The right lower extremity was then sterilely prepped and draped in usual sterile fashion. Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon. The cannula and trocar were then inserted through this, putting the patellofemoral joint. An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch. Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella. There were no loose bodies noted in the either gutter. Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted. While in this area, attention was directed to establish the inferomedial instrument portal. This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line. A probe was then inserted through this portal and the meniscus was further probed. Again, there was noted to be no meniscal tear. The knee was taken through range of motion and there was no chondromalacia. Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign. PCL was also noted to be intact. Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns. It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle. An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus. It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee. Pictures were taken both pre-meniscal resection and post-meniscal resection. The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured. The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact. Next, attention was directed to the inner surface of the patella. This was debrided using the 2.5 arthroscopic shaver. It was noted to be quite smooth and postprocedure the patient was taken ________ well. The knee was then copiously irrigated and suctioned dry and all instrumentation was removed. 20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity. At this time, Department of Anesthesia reversed the anesthetic. The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure and there were no complications.orthopedic, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2577
}
|
PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition.orthopedic, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2578
}
|
TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:, Abdominal pain.,POSTOPERATIVE DIAGNOSIS:, Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS: ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods. She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time. She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing. Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain. Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum. Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION: ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.surgery, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2579
}
|
INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED: ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:, The tip of the endoscope was introduced into the rectum. Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions. The rest of the colon through to the cecum was well visualized. The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified. There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation. Adverse reactions none.,IMPRESSION:, Normal colonic mucosa through to the cecum. There was no evidence of tumor or polyp.gastroenterology, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2580
}
|
DISCHARGE DIAGNOSIS:,1. Epigastric pain. Questionable gastritis, questionable underlying myocardial ischemia.,2. Congestive heart failure exacerbation.,3. Small pericardial effusion with no tamponade.,4. Hypothyroidism.,5. Questionable subacute infarct versus neoplasm in the pons.,6. History of coronary artery disease, status post angioplasty and stent.,7. Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago. She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon. Otherwise unremarkable. The patient follows with Dr. XYZ as an outpatient. The patient had some worsening of her symptoms over the last few days and then came to the ER. She was admitted. Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1. Epigastric pain, nausea, and vomiting. The patient was restituted with antiemetics and her symptoms improved. It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin. A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct. However, brain neoplasm could not be excluded. Other workup including a CT angio did not show any evidence of acute pulmonary emboli. It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion. The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive. She refused to complete the stress test. She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2. Congestive heart failure exacerbation. The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved. An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade. There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3. Small pericardial effusion. The patient did not have any clinical or echocardiographic evidence of tamponade.,4. Hypothyroidism. TSH was quite elevated at 19.,5. Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6. History of coronary artery disease/angioplasty and stents.,7. Hyperkalemia.,8. Patient was doing well. She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1. She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2. Cozaar 50 mg p.o. daily.,3. Aldactone 25 mg p.o. daily.,4. Synthroid 0.075 mg p.o. daily.,5. Carafate 1 gram p.o. 4 times a day.,6. Claritin 10 mg p.o. daily.,7. Lasix 20 mg p.o. daily.,8. K-Dur 20 mEq p.o. daily.,9. Prilosec 40 mg p.o. daily.,10. Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time. She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time. She is to follow up with Dr. XYZ from GI as scheduled. The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient. She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time. She will also need repeat echocardiogram done in one month for a pericardial effusion. This can be arranged by her primary care physician. Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2581
}
|
PRINCIPAL DIAGNOSIS:, Mesothelioma.,SECONDARY DIAGNOSES:, Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2. On August 20, 2007, thoracentesis.,3. On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1. Pericardectomy.,2. Pericarditis.,2. Atrial fibrillation.,4. RNCA with intracranial thrombolytic treatment.,5nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2582
}
|
CHIEF COMPLAINT:, The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:, She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:, Prenatal vitamins.,ALLERGIES:, She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS: Weight: 124 pounds. Blood pressure 96/54. Pulse: 72. Respirations: 16. LMP: 10/18/03. Age: 39.,HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation. She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen: Soft. No masses.,Pelvic: Uterus is involuting.,Rectal: She has one external hemorrhoid which has inflamed. Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:, Satisfactory three-week postpartum course, seasonal allergies. We will try Patanol eyedrops and Allegra 60 mg twice a day. She was cautioned about the possibility that this may alter her milk supply. She is to drink extra fluids and call if she has problems with that. We will try ProctoFoam HC. For the hemorrhoids, also increase the fiber in her diet. That prescription was written, as well as one for Allegra and Patanol. She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon. She will call and return if she continues to have problems with allergies. Meantime, rechecking in three weeks for her final six-week postpartum checkup.obstetrics / gynecology, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2583
}
|
PREOPERATIVE DIAGNOSIS,1. Aortoiliac occlusive disease bilaterally.,2. Dementia.,POSTOPERATIVE DIAGNOSIS,1. Aortoiliac occlusive disease bilaterally.,2. Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:, General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Note that previously the patient was found to have some baseline dementia, although slight. The patient was seen and evaluated by the neurology team, who cleared the patient for surgery. The patient was taken to the operating room and general endotracheal anesthesia was administered. The abdomen was prepped and draped in the standard surgical fashion. We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally. Dissection was carried down to the level of the femoral vessels using Bovie electrocautery. The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally. Vessel loops were placed around the aforementioned arteries. After doing so, we turned our attention to beginning our abdominal dissection. We used a #10-blade scalpel to make a midline laparotomy incision. Dissection was carried down to the level of the fascia using Bovie electrocautery. The abdomen was opened and an Omni retractor was positioned. The aorta was dissected out in the abdomen. The left femoral vein was identified. There was a nicely clampable portion of aorta visible. We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis. Full-dose heparin was given. Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels. A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors. We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis. We then created our tunnels over the iliac vessels. We pulled the distal limbs over our ABF graft into the groin. We then proceeded to perform our right anastomosis first. We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries. We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally. We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries. We then removed our clamp. We opened the limb more proximally in the abdomen on the right side. We then turned our attention to the left side and similarly placed our vascular clamps. We used a #11-blade scalpel to make an arteriotomy in the vessel. We then lengthened our arteriotomy both proximally and distally again onto the SFA. We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we opened our clamps. There was no noticeable leak from the newly constructed anastomosis. We checked our proximal graft to aortic anastomosis, which was noted to be in good condition. We then gave full-dose protamine. We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion. The abdomen was closed with #1 nylon in a running fashion. The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion. The instrument and sponge count was correct at end of case. Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.cardiovascular / pulmonary, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2584
}
|
PROCEDURES:, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:, History and physical examination was performed. The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this. Opportunity for questions was provided and informed consent was obtained.,MEDICATION: ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:, None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx. The esophageal mucosa and vascular pattern appeared normal. The lower esophageal sphincter was located at 25 cm from the central incisors. It appeared normal. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which distended with excess air. Rugal folds flattened completely. Gastric mucosa appeared normal throughout. No hiatal hernia was noted. Pyloric valve appeared normal. The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional 2 biopsies were obtained for CLO testing in the antrum. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of procedure well. The patient was turned and the scope was advanced with some difficulty to the terminal ileum. The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted. Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum. Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3. The polyp was severed. There was no bleeding at the stalk after removal of the polyp head. The polyp head was removed by suction. Excess air was evacuated from the colon. The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition. Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN: ,Histologic evaluation and CLO testing. I will contact the parents next week with biopsy results and further management plans will be discussed at that time.surgery, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2585
}
|
DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes."nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2586
}
|
HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3. Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively. Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency. She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards. She complained of sweating, but has experienced no diarrhea and no change in appetite. She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:, Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:, She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use.,MEDICATIONS:, Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT: She has exophthalmos and could not close her lids completely.,Cardiovascular: tachycardia.,Neurologic: She had mild hyperreflexiveness.,LAB:, All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122. Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry. On the 2nd day of treatment, the patient still complained of chest pain. EKG again showed tachycardia. Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours. The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake. Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131. She was to return home after the iodine treatment. She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism. Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism. Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism. She should return to Endocrine Clinic in six weeks to have thyroid function tests performed. Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy. Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health. Patient was given methylcellulose ophthalmic, one drop in each eye daily. She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression. Patient will be continued on citalopram 10 mg.consult - history and phy., hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2587
}
|
EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison is made with the prior CT abdomen and pelvis dated 10/20/05. There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP. Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips. The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen. There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak. Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either. No exoluminal leakage is identified at any level. There is no retroperitoneal hematoma present. The findings are unchanged from the prior exam. ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present. There is advanced atrophy of the left kidney. No hydronephrosis is present. No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified. There is prominent streak artifact from the left total hip replacement. There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis. The bladder grossly appears normal. A hysterectomy has been performed. ,IMPRESSION:,1. No complications identified regarding endoluminal aortoiliac graft repair as described. The findings are stable compared to the study of 10/20/04. ,2. Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level. ,3. No other acute findings noted. ,4. Advanced left renal atrophy.nephrology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2588
}
|
SUBJECTIVE:, The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended. She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily. She thinks, she also has an element of office hypertension. Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka. However, when we gave her samples of that she thought they were too big for her to swallow. Basically, she is just back on her previous blood pressure regimen. However, her blood pressure seems to be better today. Her daughter says that they do check it periodically and it is similar to today’s reading. Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade. We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems. She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve. She takes Tylenol p.r.n., which seems to be enough for her. She does not think she has any acid reflux symptoms or heartburn. She does take Tums t.i.d. and also Mylanta at night. She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth. They do heal up, but then she will get another one. She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor. They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:, Mostly otherwise as above.,OBJECTIVE:,General: She is a pleasant elderly lady. She is in no acute distress, accompanied by daughter.,Vital signs: Blood pressure: 128/82. Pulse: 68. Weight: 143 pounds.,HEENT: No acute changes. Atraumatic, normocephalic. On mouth exam, she does have dentures. She removed her upper denture. I really do not see any sores at all. Her mouth exam was unremarkable.,Neck: No adenopathy, tenderness, JVD, bruits, or mass.,Lungs: Clear.,Heart: Regular rate and rhythm.,Extremities: No significant edema. Reasonable pulses. No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable. No other focal or neurological deficits grossly.,IMPRESSION:,1. Hypertension, better reading today.,2. Right arm symptoms, resolved.,3. Depression probably somewhat improved with Lexapro and she will just continue that. She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4. Perhaps a very subtle tremor. I will just watch that.,5. Osteoporosis.,6. Osteoarthritis.,PLAN:, I think I will just watch everything for now. I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half. I offered to see her for again short-term followup. However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner. She might get a flu shot here in the next few weeks. Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.general medicine, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2589
}
|
HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. The patient states that she was on the ladder on Saturday and she stepped down after the ladder. Felt some pain in her left hip. Subsequently fell injuring her left shoulder. It's unclear how long she was on the floor. She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture. Orthopedics was consulted. Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only. She presently is complaining of pain to the left shoulder. She states she also has pain to the hip with motion of the leg. She denies any numbness or paresthesias. She states prior to this, she was relatively active within her home. She does care for her daughter who has a mess. The patient denies any other injuries. Denies back pain.,PREVIOUS MEDICAL HISTORY:, Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:, Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1. PENICILLIN.,2. SULFA.,3. ACE INHIBITOR.,PRESENT MEDICATIONS,1. Lipitor 20 mg q.d.,2. Metoprolol 25 mg b.i.d.,3. Plavix 75 mg once a day.,4. Aspirin 325 mg.,5. Combivent Aerosol two puffs twice a day.,6. Protonix 40 mg q.d.,7. Fosamax 70 mg weekly.,8. Multivitamins including calcium and vitamin D.,9. Hydrocortisone.,10. Nitroglycerin.,11. Citalopram 20 mg q.d.,SOCIAL HISTORY:, She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:, Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extremities for the last several weeks. She denies endocrinopathies. Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL: The patient is alert and responsive.,EXTREMITIES: The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment. She is diffusely tender over the proximal humerus. She is unable to actively elevate her arm due to pain. The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse. She does have chronic degenerative change to the MP and IP joints of both hands. The left lower extremity, the thigh compartment is supple. She has pain with log rolling tenderness over the greater trochanter. The patient has pain with any attempt at hip flexion passively or actively. The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism. She has 2 to 3+ bilateral pitting edema pretibially and pedally. The patient has a weak motor response to the left lower extremity. She has a 1+ dorsalis pedis pulse. Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:, Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm. There is no evidence of dislocation. There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture. There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine. There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets. Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62. Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1. This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip. The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2. Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:, I have discussed this case with the emergency room physician as well as the patient. Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation. Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure. She will need cardiology clearance, which would include an echo in advance of the procedure. I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter. She presently understands and agrees with the plan.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2590
}
|
PREOPERATIVE DIAGNOSIS:, Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:, Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal. He is almost 3 years old. He presented with 2 months of irritability, vomiting, and increasing seizures. CT scan was not conclusive, but shuntogram shows no flow through the shunt.,DESCRIPTION OF PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with his head turned to the left. Scalp was clipped. He was prepped on the head, neck, chest and abdomen with ChloraPrep. Incisions were infiltrated with 0.5% Xylocaine with epinephrine 1:200,000. He received oxacillin.,He was then reprepped and draped in a sterile manner.,The frontal incision was reopened and extended along the valve. Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts. I separated the ventricular catheter from the valve, and this was a medium pressure small contour Medtronic valve. There was some flow from the ventricular catheter, but not as much as I would expect. I removed the right-angled clip with a curette and then pulled out the ventricular catheter, and there was gushing of CSF under high pressure. So, I do believe that the catheter was obstructed, although inspection of the old catheter holes did not show any specific obstructions. A new Codman BACTISEAL catheter was placed through the same hole. I replaced it several times because I wanted to be sure it was in the cavity. It entered easily and there was still just intermittent flow of CSF. The catheter irrigated very well and seemed to be patent.,I tested the distal system with an irrigation filled feeding tube, and there was excellent flow through the distal valve and catheter. So I did not think it was necessary to replace those at this time. The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve. The valve connection was secured to the pericranium with a #2-0 Ethibond suture. The wound was irrigated with bacitracin irrigation. The shunt pumped and refilled well. The wound was then closed with #4-0 Vicryl interrupted galeal suture and Steri-Strips on the skin. It was uncertain whether this will correct the problem or not, but we will continue to evaluate. If his abdominal pressure is too high, then he may need a different valve. This will be determined over time, but at this time, the shunt seemed to empty and refill easily. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss was minimal. None replaced.surgery, bactiseal, bactiseal catheter, codman bactiseal, blocked ventriculoperitoneal shunt, ventriculoperitoneal shunt revision, ventricular catheter, shunt revision, ventriculoperitoneal shunt, catheter, ventriculoperitoneal, ventricular, shunt
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2591
}
|
EXAM: , Digital screening mammogram.,HISTORY:, 51-year-old female presents for screening mammography. Patient denies personal history of breast cancer. Breast cancer was reported in her maternal aunt.,TECHNIQUE:, Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS: ,The breasts demonstrate a mixture of adipose and fibroglandular elements. Composition appears similar. Multiple tiny punctate benign-appearing calcifications are visualized bilaterally. No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen. Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings. Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.radiology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2592
}
|
HISTORY OF PRESENT ILLNESS:, The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema. He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung. This consultation was made for better control of his blood sugars. On questioning, the patient says that he does not have diabetes. He says that he has never been told about diabetes except during his last admission at Jefferson Hospital. Apparently, he was started on glipizide at that time. His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem. He is not sure. He is not following any specific diet. He says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet. He has a long history of numbness of his toes. He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts. He has had chronic back pain. There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10. So, he was smoking 2-3 packs per day. Since being started on Chantix, he says he has cut it down to half a pack per day. He does not abuse alcohol.,MEDICATIONS: ,1. Glipizide 5 mg p.o. daily.,2. Theophylline.,3. Z-Pak.,4. Chantix.,5. Januvia 100 mg daily.,6. K-Lor.,7. OxyContin.,8. Flomax.,9. Lasix.,10. Advair.,11. Avapro.,12. Albuterol sulfate.,13. Vitamin B tablet.,14. OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above. He says he has had numbness of toes for a long time. He denies any visual problems. His legs have been swelling up from time to time for a long time. He also has history of COPD and gets short of breath with minimal activity. He is also not able to walk due to his weight. He has had ulcers on his legs, which he gets discharge from. He has chronic back pain and takes OxyContin. He denies any constipation, diarrhea, abdominal pain, nausea or vomiting. There is no chest pain. He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs: Pulse rate of 89 per minute and regular. Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT: Head is normocephalic and atraumatic. Eyes, PERRLA. EOMs intact. Fundi were not examined.,Neck: Supple. JVP is low. Trachea central. Thyroid small in size. No carotid bruits.,Heart: Shows normal sinus rhythm with S1 and S2.,Lungs: Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen: Soft and obese. No masses. Bowel sounds are present.,Extremities: Show bilateral edema with changes of chronic venostasis. He does have some open weeping sores. Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1. Diabetes mellitus, type 2, new onset. At this time, the patient is on Januvia as well as glipizide. His blood sugar right after eating his supper was 101. So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet. We will continue to follow his blood sugars closely and make adjustments as needed.,2. Neuropathy, peripheral, query etiology. We will check TSH and B12 levels.,3. Lymphedema.,4. Recurrent cellulitis.,5. Obesity, morbid.,6. Tobacco abuse. He was encouraged to cut his cigarettes down to 5 cigarettes a day. He says he feels like smoking after meals. So, we will let him have it after meals first thing in the morning and last thing at night.,7. Chronic venostasis.,8. Lymphedema. We would check his lipid profile also.,9. Hypertension.,10. Backbone pain, status post back surgery.,11. Status post hernia repair.,12. Status post penile implant and removal.,13. Umbilical hernia repair.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2593
}
|
PREOPERATIVE DIAGNOSIS:, Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:, Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer. She was counseled to undergo laparoscopic staging.,FINDINGS:, During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries. No ascites was present. On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered. She was placed in a low anterior lithotomy position using Allen stirrups. The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine. There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports. The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty. The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed. There were no adhesions underlying the previous vertical midline scar. The 10-mm port was placed in the umbilicus, and the laparoscope was inserted. Remaining ports were placed under direct laparoscopic guidance. Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy. An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum. The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached. Pedicles were sealed and divided with bipolar cutting forceps. Excellent hemostasis was noted. Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery. Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps. The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially. The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally. The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy. The right infundibulopelvic ligament was divided using the bipolar cutting forceps. The mesovarium was skeletonized. A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder. Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring. The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries. The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum. The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device. The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen. The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture. The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released. The umbilical port was removed using laparoscopic guidance. The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl. The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened and taken to the post anesthesia care unit in stable condition.surgery, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2594
}
|
PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs. The patient has now begun to have comorbidities related to the obesity. The patient has attended our bariatric seminar and met with our dietician and psychologist. The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient. Consent was obtained. The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. A Foley catheter was placed for bladder decompression. All pressure points were carefully padded, and sequential compression devices were placed on the legs. The abdomen was prepped and draped in standard, sterile, surgical fashion. Marcaine was injected into the umbilicus.bariatrics, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2595
}
|
INDICATIONS:, Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:, Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:, Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview. Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY. The lung heart ratio is 0.34. There appears to be a moderate size inferoapical perfusion defect of moderate degree. The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:, Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY. We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2596
}
|
SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort. She denies any problems with cough or sputum production. No fevers or chills. Recently, she has had a bit more problems with fatigue. For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:, Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily. She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:, Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:, Noncontributory except as outlined above.,EXAMINATION:,General: The patient was in no acute distress.,Vital signs: Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT: Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.,Neck: Supple without palpable lymphadenopathy.,Chest: Chest demonstrates decreased breath sounds, but clear.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema. No skin lesions.,O2 saturation was checked at rest. On room air it was 96% and on ambulation it varied between 94% and 96%. Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis. She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1. Lupus with mild pneumonitis.,2. Respiratory status is stable.,3. Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:, At this time, I have recommended to continue her current medications. We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan. At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.cardiovascular / pulmonary, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2597
}
|
CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:, T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2598
}
|
REASON FOR VISIT:, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema. There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted. The patient had 3/5 strength in the EHL, FHL. He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee. It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee. I would like to really work on this as he has not had much up to this time. He should remain nonweightbearing. I would like to have him return in 2 weeks' time to assess his knee range of motion. He should not need x-rays at that time.soap / chart / progress notes, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2599
}
|
EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium. There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology. There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid. Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance. There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant. There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis. The small and large bowels are otherwise unremarkable. The stomach is grossly unremarkable. There is no abdominal or retroperitoneal adenopathy. There are no adrenal masses. The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance. The spleen contains several small calcified granulomas, but no evidence of masses. It is normal in size. The lung bases are clear bilaterally. The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1. Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2. Multiple uterine fibroids.,3. Prominent endometrium.,4. Followup pelvic ultrasound is recommended.obstetrics / gynecology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.