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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2700
}
|
PREOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m. Nasal trachea intubation was performed per routine. The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report. Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft. Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft. Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine. Surgical team scrubbed and gowned in usual fashion and the patient was draped. Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa. A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion. Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region. The contents of the neurovascular canal from the greater palatine foramina were identified. The hard palate was directly observed. The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine. Similar features were reflected on the contralateral side. The area was re-contoured with rongeurs. The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable. A surgical mallet then compressed this bone further into the region. A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla. Particulate bone was then placed around the remaining block of bone. A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block. The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex. Attention was brought then to the mandible. 1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given. A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body. The anterior body was found to be approximately 3 mm in height. A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved. A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible. A similar procedure was done on the contralateral side. The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair. A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws. The block of bone was further re-contoured in situ. Particulate bone was then injected into the posterior tunnels bilaterally. A piece of AlloDerm was placed over those particulate segments. The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form. The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc. The estimated blood loss in the intraoral procedure was 220 cc. Total blood loss for the procedure 320 cc. The fluid administered 300 cc. The urine out 180. All sponges were counted encountered for as were sutures. The patient was taken to Recovery at approximately 12 o'clock noon.dentistry, autologous iliac crest bone graft, to, mandible, mandibular atrophy, maxillary atrophy, facial deformity, masticatory dysfunction, iliac crest bone graft, mental foramina, iliac crest, bone, autologous, maxillary, mandibular, maxilla
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2701
}
|
PREOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:, Right carpal tunnel release.,ANESTHESIA:, Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:, We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable. No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS: ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position. The patient underwent a Bier block by the Department of Anesthesia on the upper extremity. The upper extremity was prepped and draped in usual sterile fashion and left free. Attention was drawn then to the palm of the hand. We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel. Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves. Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel. We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament. We found no evidence of tumor or space occupying lesion in the carpal tunnel. We then irrigated copiously. Tourniquet was taken down at that time and pressure was held. There was no evidence of obvious bleeders. We approximated the skin with nylon and placed a postoperative dressing with a volar splint. The patient tolerated the procedure well. She was placed back in the gurney and taken to PACU.surgery, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2702
}
|
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.podiatry, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2703
}
|
HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound was cleaned out thoroughly with tap water, and one of the navy corpsman tried to use Superglue and gauze to repair it. However, it continues to bleed and he is here for evaluation.,PAST MEDICATION HISTORY:, Significant for asthma and acne.,CURRENT MEDICATIONS: , Accutane and takes no other medications.,TETANUS STATUS: , Up-to-date.,SOCIAL HISTORY: , He is a nonsmoker. He has been drinking alcohol today, but has no history of alcohol or drug abuse.,REVIEW OF SYSTEMS: , Otherwise well. No febrile illness. No motor or sensory complaints of any sort or paresthesias in the hand.,PHYSICAL EXAM: ,GENERAL: He is in no apparent distress. He is alert and oriented x3. Mental status is clear and appropriate. VITALS SIGNS: Temperature is 98.3, heart rate 100, respirations 18, blood pressure 161/98, oxygen saturation 99% on room air by pulse oximetry, which is normal. EXTREMITIES: Right hand, he has three lacerations all over the MCP joint of his right hand, irregular shaped over the fifth MCP and then over the fourth and third half wound, similarly the lacerations. All total approximately 4 cm in length. I see no foreign bodies, just capillary refills less than 2 seconds. Radial pulses intact. There is full range of motion with no gross deformities. No significant amount of edema associated with these in the dorsum of the hand.,STUDIES: , X-rays shows no open fracture or bony abnormality.,EMERGENCY DEPARTMENT COURSE: ,The patient was anesthetized with 1% Xylocaine. Wounds were thoroughly irrigated with tap water with at least 2 liters. They were repaired with simple sutures of 4-0 Ethilon, total of 17 sutures, 16 of which were simple, one is a horizontal mattress. The patient was given Augmentin 875 mg p.o. due to the possibility of human bite wound.,ASSESSMENT: , RIGHT HAND LACERATIONS, SIMPLE X3, REPAIRED AS DESCRIBED. NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY.,PLAN: ,The patient will be given Augmentin 875 mg 1 p.o. b.i.d. for 7 days. He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane. He will take 1 p.o. every 6 hours or as needed, #12. He will follow up for suture removal in 8 days. Should he develop any signs of infection, he will come immediately here for reevaluation. He is discharged in stable condition.,general medicine, accutane, hand laceration, laceration, hand,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2704
}
|
PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion. Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly. The temporal artery was found and exposed in an extension of about 2 cm. The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology. Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion. A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm. This was also proximally and distally ligated with 6-0 Prolene and also side branch. Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well. Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.neurology, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2705
}
|
HISTORY:, A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION: ,1. Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2. History of fibromyalgia.,3. History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4. History of chronic fatigue.,5. History of hypothyroidism.,6. History of depression.,7. History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation. The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested. The patient will follow up after RAST allergy testing for further treatment recommendations. At this point, no changes in her medication were prescribed until her followup visit.soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2706
}
|
REASON FOR VISIT:, Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:, Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.neurology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2707
}
|
PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.surgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2708
}
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PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. The patient states that he had his first colonoscopy 6 years ago and it was negative. His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86. The patient does have hemorrhoidal bleed about once a week. Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss. He gets heartburn mainly with certain food such as raw onions and he has had it for years. It will typically occur every couple of weeks. He has had no dysphagia. He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS: ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired. He is married. He had 4 children. He quite smoking 25 years ago after a 35-year history of smoking. He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s. Her mother smoked and drank. Father got a mesothelioma at age 65. There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy. He has some increased urinary frequency from a history of prostatitis. He has the heartburn, which is diet dependent and the frequent rectal bleeding. He also has restless legs syndrome at night. No cardio or pulmonary complaints. No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress. BP 112/70. Pulse 80 and regular. Respirations non-labored. Height 5 feet 7-1/2 inches. Weight 209 pounds. HEENT exam: Sclerae are anicteric. Pupils equal, conjunctivae clear. No gross oropharyngeal lesions. Neck is supple without lymphadenopathy, thyromegaly, or JVD. Lungs are clear to percussion and auscultation. Heart sounds are regular without murmur, gallop, or rub. The abdomen is soft and nontender. There are no masses. There is no hepatosplenomegaly. The bowel sounds are normal. Rectal examination: Deferred. Extremities have no clubbing, cyanosis or edema. Skin is warm and dry. The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1. Family history of colon cancer.,2. Rectal bleeding.,3. Heartburn and a family history of esophageal cancer.,PLAN:, I agree with the indications for repeat colonoscopy, which should be done at least every 5 years. Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable. I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus. If he does not have it now then it should not be a significant risk in the future. The indications and benefits of EGD, colonoscopy, and IRC were discussed. The risks including sedation, bleeding, infection, and perforation were discussed. The importance of a good bowel prep so as to minimize missing any lesions was discussed. His questions were answered and informed consent obtained. It was a pleasure to care for this nice patient.consult - history and phy., heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2709
}
|
PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,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. Care was taken not to injure the ilioinguinal nerve. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a 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 the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and sent to Pathology. The stump was examined and no bleeding was noted. The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring. In this manner, an internal ring was created that admitted just the tip of my smallest finger.,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. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then 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, ilioinguinal nerve, adherent cremasteric muscle, bassini inguinal herniorrhaphy, external oblique aponeurosis, inguinal herniorrhaphy, metzenbaum scissors, external ring, blunt dissection, cord structures, bovie electrocautery, inguinal, electrocautery
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2710
}
|
PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted. This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:, Conscious sedation was achieved via propofol via the emergency department staff. Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture. This was confirmed with image intensifier. Subsequently, the patient was placed into a splint. The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION: ,Post-reduction x-rays revealed good alignment in the AP x-rays. The lateral x-rays also revealed adequate reduction. At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week.surgery, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2711
}
|
XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,letters, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma
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ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Colonoscopy.,2. Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows:,1. Coreg 12.5 mg p.o. b.i.d.,2. Lipitor 10 mg p.o. at bedtime.,3. Nitro-Dur patch 0.3 mg per hour one patch daily.,4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5. Synthroid 0.175 mg p.o. daily.,6. Zyrtec 10 mg p.o. daily.,7. Lamictal 100 mg p.o. daily.,8. Lamictal 150 mg p.o. at bedtime.,9. Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10. Nexium 40 mg p.o. at breakfast.,11. Neurontin 400 mg p.o. t.i.d.,12. Lasix 40 mg p.o. b.i.d.,13. Fentanyl 50 mcg patch transdermal q.72h.,14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16. Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP: ,The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.nan
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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.soap / chart / progress notes, daytime frequency, psa, irritative symptoms, elevated psa, frequency, nocturia
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HISTORY:, A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic. A is a 17-year-old male with oligoarticular arthritis of his right knee. He had a joint injection back in 03/2007 and since then he has been doing relatively well. He is taking Indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day. He denies any swelling more than what it was before, and he denies any other joints are affected at this moment. Denies any fevers or any rashes.,PHYSICAL EXAMINATION:, On physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80. He is alert, active, and oriented in no distress. He has no facial rashes, no lymphadenopathy, no alopecia. Funduscopic examination is within normal limit. He has no cataracts and symmetric pupils to light and accommodation. His chest is clear to auscultation. The heart has a regular rhythm with no murmur. The abdomen is soft and nontender with no : visceromegaly. Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness. Lower extremities: He still has some weakness of the knees, hip areas, and the calf muscles. He does have minus/plus swelling of the right knee with a very hypermobile patella. There is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,In terms of his laboratories, they were not done today.,ASSESSMENT: , This is a 17-year-old male with oligoarticular arthritis. He is HLA-B27 negative.,PLAN:, In terms of the plan, I discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day. I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an MRI. We will see him back in three months. He was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities. Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI. Today he received his flu shot. Discussed this with A and his aunt and they had no further questions.consult - history and phy., rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling,
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HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,nan
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DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL: The patient is alert, in no respiratory distress.,VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK: Supple.,CHEST: Clear breath sounds.,CARDIAC: Normal S1, S2 without murmur.,ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness.,SKIN: Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:, Regular as tolerated.,DISCHARGE MEDICATIONS: ,1. Ciprodex Otic Solution in the right ear twice daily.,2. Augmentin 500 mg three times daily x10 days.,FOLLOW UP: ,1. Dr. Y in one week (ENT).,2. The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.
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PREOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS: ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy. He was initially dry without pads and then underwent salvage radiation therapy for rising PSA. After that he began with episodes of incontinence as well as urinary retention requiring catheterization. One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy. He had retained staple removed and a diverticulum identified. There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time. He wears 8 to 10 pads per day, and this has affected his quality of life significantly. I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck. We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him. I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel. The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally. The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment. Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL: ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion. A nasogastric tube was placed as well as radial arterial line. He was given intravenous antibiotics for prophylaxis. A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described. Moist wound towels and a Bookwalter retractor were placed for exposure. We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum. The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips. An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries. This was quite challenging because of the previous radiation therapy and radical prostatectomy. We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally. We then approached things posteriorly and carefully dissected between the __________ and posterior bladder. There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum. We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum. We then peeled it off the remaining rectum and passed the specimen off the operative field. Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon. This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch. I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. The colon was divided proximal to the middle colic using a GIA-80 stapler. I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler. We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60. The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler. The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures. The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75. Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis. The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture. The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture. The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis. The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. We then matured our stoma through the umbilicus. We removed the plug of skin through the umbilicus and delivered the ileal segment through this. A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures. The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches. The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant. A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia. Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips. The estimated blood loss was 450 mL, and the patient received no packed red blood cells. The final sponge and needle count were reported to be correct. The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.surgery, radiation cystitis, voiding dysfunction, retropubic prostatectomy, salvage radiation therapy, salvage cystectomy, indiana pouch continent cutaneous diversion, omental pedicle flap, ligasure, gia, stapler, gia stapler, vicryl sutures, radiation therapy, silk sutures, bladder, therapy, sutures, endotracheal,
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PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1. Incision and drainage, left elbow.,2. Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION: ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage. He was then scheduled for I&D and excision of the bursa. Risks and benefits were discussed. No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine. The left upper extremity was prepped and draped in standard sterile fashion. On examination of the left elbow, there was presence of thickening of the bursal sac. There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted. An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin. The incision was carried proximally and distally. The olecranon bursa was significantly thickened and scarred. Excision of the olecranon bursa was performed. There was significant evidence of thickening of the bursa with some evidence of adhesions. Satisfactory olecranon bursectomy was performed. The wound margins were debrided. The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution. There was no evidence of a loose body. There was no bleeding or drainage. After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion. The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient tolerated the procedure very well. He was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noticed.orthopedic, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa
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{
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HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1. Right ruptured ectopic pregnancy with hemoperitoneum.,2. Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy.discharge summary, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic,
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SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heartburn and/or gastroesophageal reflux disorder. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC. The patient was seated upright in a video imaging chair throughout this assessment. To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:, Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid. Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation. Penetration was noted with cup sips of thin liquid only. Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies. The patient's hyolaryngeal elevation and anterior movement are within functional limits. Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus. Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:, No aspiration was noted during this evaluation. Penetration with cup sips of thin liquid. The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1. The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2. The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3. The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.consult - history and phy., gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration
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}
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DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge.discharge summary, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2722
}
|
PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. Preparation was good, although there was some residual material in the cecum that was difficult to clear completely. The mucosa was normal throughout the colon. No polyps or other lesions were identified, and no blood was noted. Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation. A retroflex view of the anorectal junction showed no hemorrhoids. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Diverticulosis in the sigmoid.,2. Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. Screening colonoscopy in 2 years.,3. Additional evaluation for other causes of anemia may be appropriate.surgery, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2723
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp: Patient denies asthma, lung infections and lung lesions.,GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology: Patient denies allergic reactions, rashes and skin lesions.,MEDS:, Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:, No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:, No significant family history.,REVIEW OF SYSTEMS:, Non-contributory.,Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.,Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.,Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.,Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.,Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.,Extremities: There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled. Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC. ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2724
}
|
PREOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,PROCEDURE PERFORMED: ,Excision of left breast mass and revision of scar.,ANESTHESIA: ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION: ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY: ,The patient is an 18-year-old female who presented to Dr. X's office. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. The patient also has a hypertrophic scar. Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed. The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion. Elliptical incision was made over the previous cicatrix. The total length of the incision was 5.5 cm. Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine. Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery. Hemostasis was maintained. Attention was next made to approximating the deep dermal layers. An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges. Steri-Strips as well as bacitracin and sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition.hematology - oncology, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2725
}
|
REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested. The patient denies any chest pain or shortness of breath. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At this time, he is on:,1. Atrovent and albuterol nebulizers.,2. Azithromycin.,3. Potassium chloride 10 mEq p.o. daily.,4. Furosemide 20 mg IV daily.,5. Enoxaparin 40 mg daily.,6. Lisinopril 10 mg p.o. daily.,7. Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:, History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke. Drinks occasionally.,FAMILY HISTORY: ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea. He has cough. No fever. No abdominal pain. No syncope, near-syncope, or palpitation. All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable, not in distress.,VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT: Atraumatic, normocephalic. Eyes PERRLA.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Clear.,HEART: S1 and S2, regular. No S3. No S4. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,DIAGNOSTIC DATA:, EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay. CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. Loculated pleural effusion in the left upper lobe. No PE. Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05. White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1. Pneumonia.,2. Diastolic heart failure, not contributing to his present problem.,3. Hypertension, controlled.,4. History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics. No further cardiac workup at this time.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2726
}
|
SUBJECTIVE:, This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college. She denies any problems at this time. Her last Pap smear was 06/25/2003 and was normal. She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time. We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:, Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:, None.,SOCIAL HISTORY:, Denies tobacco or drug use, rare alcohol use. She is sexually active and has had one partner.,FAMILY HISTORY: ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:, HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs: Height 5 feet 6 inches. Weight 153 pounds. Blood pressure 106/72. Pulse 68. Respirations 12. Temperature 97.5. Last menstrual period 05/30/2004.,General: She is a well-developed, well-nourished white female in no acute distress.,HEENT: Tympanic membranes unremarkable. Oropharynx nonerythematous. Pupils equal, round, and reactive to light. Extraocular muscles intact.,Neck: Supple. No lymphadenopathy and no thyromegaly.,Chest: Clear to auscultation bilaterally.,CV: Regular rate and rhythm without murmur.,Abdomen: Positive bowel sounds. Soft and nontender. No hepatosplenomegaly.,Breasts: No nipple discharge. No lumps or masses palpated. No dimpling of the skin. No axillary lymph nodes palpated. Self-breast exam discussed and encouraged.,Pelvic: Normal female genitalia. Normal vaginal rugation. No cervical lesions. No cervical motion tenderness. No adnexal tenderness or masses palpated.,Extremities: No cyanosis, clubbing, or edema.,Neurologic: 2+/4 DTRs in all extremities. 5/5 motor strength in all extremities. Negative Romberg.,Musculoskeletal: No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1. Complete physical, Pap, and breast exam completed.,2. School physical form completed and returned to the patient.,3. Hepatitis B second injection will be given today.,4. Contraceptive surveillance. We will put patient to Seasonale to start at the end of this cycle a pill.,5. Allergic rhinitis. Prescription was given for Allegra 180 mg q.d. #30 carrying refills for her to take with her school Cowley County Community College.,6. Insomnia. Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school. She will follow up as needed.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2727
}
|
SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2728
}
|
CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse. He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:, Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS: ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS: ,Documented on the template. Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. Oxygen saturation low at 91% on room air.,GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular motions are intact and conjugate. Clear TMs, nose, and oropharynx.,NECK: Supple. Full painless nontender range of motion.,CHEST: Tight wheezing and retractions heard bilaterally.,HEART: Regular without rubs or murmurs.,ABDOMEN: Soft, nontender. No masses. No hepatosplenomegaly.,GENITALIA: Male genitalia is present on a visual examination.,SKIN: No significant bruising, lesions or rash.,EXTREMITIES: Moves all extremities without difficulty, nontender. No deformity.,NEUROLOGIC: Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:, The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. She is further treated in the emergency department with continued breathing treatments. At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells. Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2729
}
|
CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:, This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma.,Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative.,PMH: , Acne. Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single. Living at home. No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES: ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS: Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL: This is a 16-year-old white female. She is awake, alert, and oriented x3. She does appear bit uncomfortable.,HEAD: Normocephalic and atraumatic.,EYES: The pupils were equal and reactive to light. Extraocular movements are intact.,ENT: TMs are clear. Nose and throat are unremarkable.,NECK: There is no evidence of nuchal rigidity. She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles. Palpation clearly causes having exacerbation of her discomfort.,CHEST: Thorax is unremarkable.,GI: Abdomen is nontender.,MUSCLES: Extremities are unremarkable.,NEURO: Cranial nerves II through XII are grossly intact. Motor and sensory are grossly intact. ,SKIN: Skin is warm and dry.,ED COURSE:, The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1. Muscle tension cephalgia.,2. Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20. She was instructed to apply warm compresses and perform gentle massage. Follow up with regular provider as needed. Return if any problems.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2730
}
|
EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2731
}
|
PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1. Radical retropubic prostatectomy, robotic assisted.,2. Bladder suspension.,ANESTHESIA:, General by intubation.,The patient understands his diagnosis, grade, stage and prognosis. He understands this procedure, options to it and potential benefits from it. He strongly wishes to proceed. He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE: ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion. My camera ports were then placed in the standard fan array. A camera port was placed in the midline above the umbilicus using the Hasson technique. The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision. My assistant was on the right. The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis. This nicely exposed the space of Retzius. I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally. The levator ani muscles were carefully dissected free from the prostate and pushed laterally. Dissection was continued posteriorly toward the bundles and caudally to the apex. The puboprostatic ligaments were then transected. A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck. The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound. I then transected the posterior bladder neck down to the level of the ampullae of the vas. The ampullae were mobilized and transected. These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized. Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply. Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles. I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water. Hemostasis was found to be complete. I then carried out a urethrovesical anastomosis. This was accomplished with 3-0 Monocryl ligatures. Two of these were tied together in the midline. They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied. A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation. The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension. This was done in hopes of obtaining early urinary control. This was accomplished with 0 Vicryl ligatures. One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis. This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision. A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk. The camera port fascia was closed with running 0 Vicryl. The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well. There were no complications. Sponge and instrument counts were reported correct at the end of the case.surgery, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2732
}
|
PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS: ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis. She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones. After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. She was positively identified and the correct surgical site and procedure reviewed. After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created. The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg. A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity. Upper abdominal anatomy was normal. Pelvic laparoscopy revealed bilaterally closed internal inguinal rings. Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____. There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region. Using these, the gallbladder was grasped and retraced cephalad. Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction. A small ductotomy was created. Reddick cholangiogram catheter was then placed within the duct and the balloon inflated. Continuous fluoroscopy was used to instill contrast material. This showed normal common bile duct which entered the duodenum without obstruction. There was no evidence of common bile duct stones. The cholangiogram catheter was removed. The duct was doubly clipped and divided. The artery was divided and cauterized. The gallbladder was taken out of the gallbladder fossa. It was then placed in Endocatch bag and left in the abdomen. Attention was then paid to the appendix. The appendix was identified and window was made in the mesoappendix at the base. This was amputated with an Endo-GIA stapler. The mesoappendix was divided with an Endo-GIA vascular stapler. This was placed in another Endocatch bag. The abdomen was then irrigated. Hemostasis was satisfactory. Both the appendix and gallbladder were removed and sent for pathology. All trocars were removed. The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures. The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide. The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture. The skin was cleaned. Mastisol, Steri-Strips and band-aids were applied. The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.gastroenterology, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2733
}
|
PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,pediatrics - neonatal, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2734
}
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PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:, Positive for only for left knee arthritis. She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers. She has no skin rashes. She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left. There is an afferent pupillary defect on the right. On examination, there is a right hypertropia. There is dense anterior chamber inflammation on the right eye with a stagnant aqueous. There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern. This seems to be complete iris synechia to the anterior lens capsule. There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface. The anterior chamber appears narrow. On the left, there is also dense inflammation at 4+ cell. There is 1+ nuclear sclerosis. Dilated fundus examination cannot be performed on the right secondary to intense inflammation. On the left, there is no evidence of active posterior uveitis. There is some inferior vitreous debris.,ASSESSMENT/PLAN:, Chronic bilateral recurrent nongranulomatous diffuse uveitis. Currently, there is very severe right eye inflammation and severe left eye. I discussed at length with the patient that this will likely take an oral steroid to quite her down. Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible. She has been on oral steroids in the past. We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left. I anticipate we will likely start methotrexate in the near future. In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate. We will watch her closely in clinic. I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past. At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR. Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.ophthalmology, iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2735
}
|
INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal. At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise. At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise. At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina. MRI of the thoracic spine showed normal vertebral body height and alignment. There was evidence of disc generation, especially anteriorly at the T5-T6 level. There was no significant central canal or foraminal compromise. Thoracic cord normal in signal morphology. MRI of the lumbar spine showed normal vertebral body height and alignment. There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4. There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess. The transversing nerve root on the right was impinged at that level. The right foramen was mildly compromised. There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing. There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion. This was also seen on a prior study.,radiology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: 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.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2736
}
|
DISCHARGE DIAGNOSES:,1. Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2. Prostatic hypertrophy with bladder outlet obstruction.,3. Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks. He will be followed in the office.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 62-year-old male with cerebral palsy. The patient was recently admitted to Hospital with lower extremity cellulitis. This resolved, however, recurred in both legs. Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:, As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION: ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000. Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8. Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria. Blood culture and wound cultures were unremarkable. Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin. On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine. A Foley catheter was inserted and was productive of approximately 500 cc of urine. The patient was prescribed Flomax 0.4 mg daily. 24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.neurology, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2737
}
|
CHIEF COMPLAINT:,1. Stage IIIC endometrial cancer.,2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:soap / chart / progress notes, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2738
}
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PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED: ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS: ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room, placed in supine position in the operating table. Intravenous sedation was administered by the Anesthesia Department. The Kopans wire was trimmed to an appropriate length. The patient was sterilely prepped and draped in the usual manner. Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision. A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire. The wire was stabilized and brought to protrude through the incision. Skin flaps were then generated with electrocautery. A generous core tissue was grasped with Allis forceps and excised with electrocautery. Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short. The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along. The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well.obstetrics / gynecology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2739
}
|
PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Endometriosis.,3. Prior right salpingo-oophorectomy.,4. History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1. Endometriosis.,2. Interloop bowel adhesions.,PROCEDURE PERFORMED:,1. Total abdominal hysterectomy (TAH).,2. Left salpingo-oophorectomy.,3. Lysis of interloop bowel adhesions.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions. On bimanual exam, the uterus was enlarged, movable, and anteverted. The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation. The uterus was found to be normal in size with evidence of endometriosis on the uterus. The right ovary and fallopian tube were absent. The left fallopian tube and ovary appeared normal with evidence of a small functional cyst. There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected. There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent. There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis. She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy. She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia. She was then prepped and draped in the sterile fashion and placed in the dorsal supine position. An indwelling Foley catheter was placed. With the skin knife, an incision was made removing the old cicatrix. A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie. The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie. The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly. The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder. At this point, the intraabdominal cavity was manually explored and the above findings were noted. A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field. The bowel was then packed with moist laparotomy sponges. Prior to this, the filmy adhesions leftover were taken down. At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl. At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created. The posterior aspect of the peritoneum was also dissected. At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle. Two hemostats were then placed across the pedicle and this was transected with the scalpel. This was then suture ligated in Heaney fashion. The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament. This was then ligated with three tie of #0 Vicryl. Also incorporated in this was the remnant from the previous right salpingo-oophorectomy. At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed. In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed. These ligaments bilaterally were transected and suture ligated in a left Heaney stitch. At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated. Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated. Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl. At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix. The roticulator was then clamped and removed and the staple line was in place. This was found to be hemostatic. A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally. At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum. There did appear to be good support on palpation. Prior to this, the specimen was handed off and sent to pathology. At this point, there did appear to be small amount of oozing at the right peritoneum. Hemostasis was obtained using a #0 Vicryl in two single stitches. Good hemostasis was then obtained on the cuff as well as the pedicles. Copious irrigation was performed at this point with lactate Ringers. The round ligaments were then incorporated into the cuff bilaterally. Again, copious amount of irrigation was performed and good hemostasis was obtained. At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally. At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel. Good hemostasis was obtained of these sites as well. The sigmoid colon was then returned to its anatomic position and the omentum as well. The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl. The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline. The Scarpa's fascia was then closed with #3-0 plain in a running suture. The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure. This was dressed with an Op-Site. The patient tolerated the procedure well. The sponge, lap, and needle were correct x2. After the procedure, the patient was extubated and brought out of general anesthesia. She will go to the floor where she will be followed postoperatively in the hospital.obstetrics / gynecology, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2740
}
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CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints.,REVIEW OF SYSTEMS:, CONSTITUTIONAL: No fever or chills. No fatigue or weakness. HEENT: No headache. No neck pain. No eye pain or vision change. No rhinorrhea. No sinus congestion, pressure, or pain. No sore throat. No throat swelling. The patient does have the toothache on the left lower side that radiates towards his left ear as previously described. The patient does not have ear pain or hearing change. No pressure in the ear. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath. GASTROINTESTINAL: No nausea or vomiting. No abdominal pain. MUSCULOSKELETAL: No back pain. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No speech change. HEMATOLOGIC/LYMPHATIC: No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:, None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana. The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be healthy. The patient is calm, comfortable in no acute distress, looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctivae bilaterally. Nose, normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. Ears are normal without any sign of infection. No erythema or swelling of the canals. Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. MOUTH: The patient has a dental fracture at tooth #18. The patient states that the fracture is a couple of months old. The patient does not have any obvious dental caries. The gums are normal without any erythema, swelling, or evidence of infection. There is no fluctuance or suggestion of abscess. There is slight tenderness of the tooth #18. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion, or swelling. Mucous membranes are moist. Floor of the mouth is normal without any tenderness or swelling. No suggestion of abscess. There is no pre or post auricular lymphadenopathy either. NECK: Supple. Nontender. Full range of motion. No meningismus. No cervical lymphadenopathy. No JVD. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to the back, arms, or legs. The patient has normal use of the extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. No evidence of clinical intoxification. HEMATOLOGIC/LYMPHATIC: No lymphadenitis is palpated.,DIAGNOSES:,1. ACUTE LEFT JAW PAIN.,2. #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3. ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation. The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain. The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain. He was given precautions for drowsiness and driving with the use of this medication. The patient was also given a prescription for pen V. The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.consult - history and phy., jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2741
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PREOPERATIVE DIAGNOSIS:, Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth. ICD9 Code: 528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS: ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:, 40 Ml.,FLUID: ,700 mL of crystalloid.,COMPLICATIONS: ,None.,CONDITION: ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE: ,The patient is a 41-year-old that has a recent history of toothache and tooth pain. She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions. The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment. She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse. The patient was admitted to the hospital on Monday for IV antibiotics. Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain. The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery. It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room and laid on the operating room table on supine fashion. ASA monitors were attached as stated. General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space. This pus was then cultured and sent to micro lab for cultures and sensitivities. Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate. After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case. Mouth rinse was then poured into the oral cavity. The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction. Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space. It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay. Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5. It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed. Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed. The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file. Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed. This site was then irrigated with copious amounts of sterile water. There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct. A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed. A little-to-no pus was received. Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture. Remainder of the flap was left open to drain. Further examination of the floor of mouth was soft. The lateral pharynx was nonindurated or swollen. At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated. The procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition.surgery, cultures, buccal, teeth, canine, pacu, teeth extractions, oromaxillary facial, facial surgery, buccal space, throat pack, buccal mucosa, surgical removal, canine's base, necrotic teeth, cpt code, infection, oral, mucosa, anesthesia, facial, pus, toothache,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2742
}
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PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:, Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient. She was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse. Approximately 6 mL of 5% phenol was injected in this location. At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.neurology, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectoralis major, botulinum toxin, pectoralis, botulinum, phenol, injection, toxin
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2743
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders. As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center. The patient was evaluated in the emergency room. The initial cardiac workup was negative. The patient was admitted to telemetry unit for further evaluation. In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine. The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer. None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009. The patient is admitting to having a recent abortion done. She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: ,She lives with her boyfriend. The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS: As mentioned above.,PHYSICAL EXAMINATION:,GENERAL: She is alert, awake, and oriented.,VITAL SIGNS: Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT: Shows head is atraumatic. Pupils are round and reactive to light. Extraocular muscles are intact. No oropharyngeal lesions noted.,NECK: Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Reveals regular rate and rhythm.,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are normally present.,LOWER EXTREMITIES: Shows no edema. Distal pulses are 2+.,NEUROLOGICAL: Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal. Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal. The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal. EKG is normal, sinus rhythm without any acute ST-T wave changes. As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana. The patient also had a head CT done in the emergency room, which was fairly unremarkable. The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1. Chest pains, appear to be completely noncardiac. The patient does seem to have a psychosomatic component to her chest pain. There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2. Possible early pregnancy. The patient's case was discussed with OB/GYN on-call over the phone. Some of the medications have to be held secondary to potential danger. The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3. Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control. Again, this is an outpatient diagnosis. The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2744
}
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EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.radiology, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2745
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EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm. It appears to be completely replaced by multiple ill-defined fibroids. The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids. The right ovary measures 3.9 x 1.9 x 2.3 cm. The left ovary is not seen. No complex cystic adnexal masses are identified.,IMPRESSION: ,Essential replacement of the uterus by fibroids. It is difficult to measure given their heterogenous and diffuse nature. MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.obstetrics / gynecology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2746
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ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS: ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003. Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery. Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery. The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen. Her Apgars were 8 at 1 minute and 9 at 5 minutes. At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE: ,The infant has had a basically uncomplicated hospital course. She did not require oxygen. She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus. The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1. She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS: At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT: Head is normocephalic. Eyes are without conjunctival injection. Red reflex is elicited bilaterally. TMs not well visualized. Nose and throat are patent without palatal defect.,NECK: Supple without clavicular fracture.,LUNGS: Clear to auscultation.,HEART: Regular rate without murmur, click or gallop present.,EXTREMITIES: Pulses are 2/4 for brachial and femoral. Extremities without evidence of hip defects.,ABDOMEN: Soft, bowel sounds present. No masses or organomegaly.,GENITALIA: Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL: The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home. She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003. She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2747
}
|
REASON FOR VISIT:, Syncope.,HISTORY:, The patient is a 75-year-old lady who had a syncopal episode last night. She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today. She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink. She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL: Lady in no distress.,VITAL SIGNS: Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20. Afebrile.,HEENT: Head is normal.,NECK: Supple.,LUNGS: Clear to auscultation and percussion.,HEART: No S3, no S4, and no murmurs.,ABDOMEN: Soft.,EXTREMITIES: Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT: ,Syncope.,PLAN: ,She had a CT scan of the brain that was negative today. The blood pressure is high. We will start Maxzide. We will do an outpatient Holter and carotid Doppler study. She has had an echocardiogram along with the stress test before and it was normal. We will do an outpatient followup.emergency room reports, residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2748
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|
MEDICAL DIAGNOSIS:, Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS: ,Global aphasia.,SUBJECTIVE: ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history. Based on the sister-in-law's report, the patient had a stroke on 09/19/08. The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks. ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson. The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana. In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time. Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school. During the case history, I did pose several questions to the patient, but her response was often "no." She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE: ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed. Also tests were not done due to time constraint and the patient's severe difficulty and emotional state. Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:, Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia. On the spontaneous speech subtest, the patient responded "no" to all questions asked except for how are you today where she gave a thumbs-up. She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly. The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered "no" to all "yes/no" questions. The auditory word recognition subtest, the patient had 5 out of 60 responses correct. With the sequential command, she had 10 out of 80 corrects. She was able to shut her eyes, point to the window, and point to the pen after directions. With repetition subtest, she repeated bed correctly, but no other stimuli. At this time, the patient became very emotional and repeatedly stated "I can't". During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon. The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech. In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task. She is not able to state the days of the week or months in the year or her name at this time. She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION: ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication. She does perseverate and is very emotional due to probable frustration. Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks. Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1. The patient will answer simple "yes/no" questions with greater than 90% accuracy with minimal cueing.,2. The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3. The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4. The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5. The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):, Functional communication abilities to allow the patient to express her basic wants and needs.consult - history and phy., speech automatic tasks, minimal cueing, sentence completion, western aphasia battery, skilled speech therapy, global aphasia, speech therapy, speech, aphasia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2749
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REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting. The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan. Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen. The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations. This section of small bowel was resected, and a wound VAC placed for damage control. Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel. The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU.,PAST MEDICAL HISTORY:, Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD.,PAST SURGICAL HISTORY:, Included a cardiac cath with no interventions taken.,HOME MEDICATIONS:, Include Lantus insulin as well as oral hypoglycemics.,CURRENT MEDS:, Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin. Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold.,REVIEW OF SYSTEMS:, Unable to be obtained secondary to the patient's intubated and sedated status.,ALLERGIES: , None.,FAMILY HISTORY:, Includes diabetes on his father side of the family. No other information is provided.,SOCIAL HISTORY:, Includes tobacco use as well as alcohol use.,PHYSICAL EXAMINATION:,GENERAL: The patient is currently intubated and sedated on Levophed drip.,VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm.,NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well. He does arouse with suctioning, but is unable to open his eyes to commands.,HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted. He has no scleral icterus. His mucous membranes are pink, but dry. He has an EG tube, which is currently 24-cm at the lip. He has a left-sided subclavian vein catheter, triple lumen.,NECK: His neck is without masses or lymphadenopathy or JVD.,CHEST: Chest has diminished breath sounds bilaterally.,ABDOMEN: Abdomen is soft, but distended with a wound VAC in place. Groins demonstrate a left-sided femoral outline.,EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left. His toes are cool, and pulses are not palpable.,LABORATORY EXAMINATION: , Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22. After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively. LFTs are all normal. Amylase and lipase are normal. Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211. UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria. Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles. Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,ASSESSMENT AND PLAN:, This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion. He is status post small bowel resection. We plan to go back to operating room tomorrow for further debridement and possible closure. Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands. I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal. Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator. We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.,1. Cardiovascular. The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70. We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock. Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time. If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function. Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2. Pulmonology. Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60. We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise. We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.,3. Gastrointestinal. The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV. He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum. We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube. I will keep him on GI prophylaxis as he is intubated. We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes. He will have a long-term TPN after this acute episode. His LFTs are all normal currently. Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.,4. Renal. The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium. His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail. He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip. Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis. We will re-consult Nephrology at this time.,5. Endocrine. The patient has adrenal insufficiency based on lack of stem to cosyntropin. We will start hydrocortisone 50 q.6h.,6. Infectious Disease. Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially. Given his bowel ischemia, we will continue these, and appreciate ID service's input.,7. Hematology. Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration. We will restart the Angiomax once he is back from the OR tomorrow. Currently, his INR is 2.2. Therefore, he should be covered at the moment. Appreciate the Hematology's input in this matter.,Please note the total critical care time spent at the bedside excluding central line placement was 1 hour.nan
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{
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"dataset_name": "medical-transcription-4",
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PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:, Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office. Due to the severe cramping, a decision to undergo vacuum D&C was made. At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE: ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department. The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion. A weighted vaginal speculum was placed in the posterior vaginal vault. Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight. Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue. This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction. Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure. Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed. The patient was repositioned to supine position and taken to recovery room in stable condition.obstetrics / gynecology, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,
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{
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"dataset_name": "medical-transcription-4",
"id": 2751
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PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. It was accompanied by diaphoresis and shortness of breath. The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5. Stress images revealed left ventricular dilatations suggestive of multivessel disease. He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed. The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. The needle was removed and a pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed and the sheath was flushed. A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. This catheter was removed. The sheath was flushed the final time. The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:, This vessel is seen to be heavily calcified throughout its course. Begins as a moderate caliber vessel. There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, This vessel is heavily calcified in its proximal portion. It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. There is sequential 80% and 90% stenosis in the mid-portion of the vessel. Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY: ,This vessel is also calcified in its proximal portion. There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system. There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1. Three-vessel coronary artery disease as described above.,2. Moderate mitral regurgitation per TEE.,3. Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4. Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2752
}
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PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:, Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY: ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting. He was referred to me for that reason to be treated under general anesthesia for his dental work. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. There are no contraindications to this procedure. He is healthy. His history and physical is in the chart.,PROCEDURE: ,The patient was brought to the operating room at 10:15 and placed in the supine position. Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined. A throat pack was then placed. Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite. Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite. Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite. Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary. This was done using ferric sulfate and zinc oxide eugenol. For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly. The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30. There was no blood loss.dentistry, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2753
}
|
PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 10 mL,COMPLICATIONS:, None.,SPONGE COUNT: , Correct x2.surgery, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2754
}
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HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicuspid aortic valve was also seen without insufficiency or stenosis. The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE: ,After sedation and general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place. There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle. A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery. The transverse arch measured 5 mm. Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level. The diaphragm measured 5.6 mm. The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery. This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist. Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient. Repeat angiogram showed mild improvement in degree of aortic narrowing. The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist. The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the pediatric intensive care unit in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to mild systemic arterial desaturation and anemia. There is no evidence of significant intracardiac shunt. Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta. The calculated flows were mildly increased. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels. There is discrete juxtaductal coarctation of the aorta. Flow within the intercostal arteries was retrograde. Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg. There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta. The calculated systemic flow fell to normal values. Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus. There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries. The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES: ,1. Juxtaductal coarctation of the aorta.,2. Dilated cardiomyopathy.,3. Bicuspid aortic valve.,4. Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference. The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery. The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months. The further cardiologic care will be directed by Dr. X.surgery, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2755
}
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TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY: ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death. This list was inclusive, but not exclusive. An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS: ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room. After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table. Lumbar spine was shaved, prepped, and draped in the usual sterile fashion. An incision was carried out from L4 to S1. Hemostasis was obtained with bipolar and Bovie cauterization. A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum. At this time, laminectomy was carried out of L5-S1. Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space. At this time, the disk was entered with a #15 blade and bipolar. The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk. We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root. Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic. At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound. There were no complications.orthopedic, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2756
}
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PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS: ,Gross hematuria.,OPERATIONS: ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS: ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed. There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs. The patient had hematuria. Cystoscopy revealed atypical biopsy. The patient came in again with gross hematuria. The first biopsy was done about a month ago. The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria. The options of watchful waiting, removal of the clots and biopsies were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed. Morbidity and mortality of the procedure were discussed. Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. The patient had been off of the Coumadin for about 4 days and INR had been reversed. The patient has significant amount of clot upon entering the bladder. There was a tight bladder neck contracture. The prostate was not enlarged. Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed. It took about half an hour to just remove the clots. After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected. This was lateral to the left ureteral opening. The base was coagulated for hemostasis. Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized. The back wall and the rest of the bladder appeared normal. Using 8-French cone-tip catheter, left-sided pyelogram was normal. The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation. The patient did have CT with contrast, which showed that the kidneys were normal. At this time, a #24 three-way irrigation was started. The patient was brought to Recovery room in stable condition.surgery, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2757
}
|
EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis. Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:, Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava. Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina. Sternotomy wires are noted. They appear in appropriate placement. There are no focal areas of consolidation to suggest pneumonia. Once again seen is minimal amount of bilateral basilar atelectasis. The cardiomediastinal silhouette appears to be within normal limits at this time. No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1. There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2. Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3. Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.cardiovascular / pulmonary, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2758
}
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PREOPERATIVE DIAGNOSIS:, Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:, General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:, Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:, 10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure. Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located. The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle. Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures. Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision. Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity. A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction. Periosteal elevator was used to explore the area near the extraction site. This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site. No drain was placed. Upon completion of the procedure, the throat pack was removed. The pharynx was suctioned. The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.dentistry, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2759
}
|
CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful. He had no voiding or stooling problems. No nausea, vomiting or fever. Family denies trauma or dysuria. At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved. He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning. He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation. He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago. He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:, The patient has no known allergies. He is term delivery via spontaneous vaginal delivery. He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:, All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking. He is not in school.,MEDICATIONS:, He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS: On physical exam, weight is 15.9 kg.,GENERAL: The patient is a cooperative little boy.,HEENT: Normal head and neck exam. No oral or nasal discharge.,NECK: Without masses.,CHEST: Without masses.,LUNGS: Clear.,CARDIAC: Without murmurs or gallops.,ABDOMEN: Soft. No masses or tenderness. His scrotum did not have any swelling at the present time. There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted. No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only. His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES: He had full range of motion in all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left. This is personally reviewed by me. The right was normal. No masses were appreciated. There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem. If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found. I discussed the pre and postsurgical care with the parents. Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure. The parents understand and wished to proceed. We will schedule this later today emergently.nan
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{
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"dataset_name": "medical-transcription-4",
"id": 2760
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PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.surgery, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2761
}
|
PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,POSTOPERATIVE DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:, A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9. There was normal pelvic anatomy, normal tubes. The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip. The abdomen was prepped and draped in a sterile fashion. A Pfannenstiel incision was made and carried sharply down to the level of fascia. The fascia was incised transversely. The fascia was dissected away from the underlying rectus muscles. With sharp and blunt dissection, rectus muscles were divided in midline. The perineum was entered bluntly. The incision was carried vertically with scissors. Transverse incision was made across the bladder peritoneum. The bladder was dissected away from the underlying lower uterine segment. Bladder retractor was placed to protect the bladder. The lower uterine segment was entered sharply with a scalpel. Incision was carried transversely with bandage scissors. Clear amniotic fluids were encountered. The infant was out of the pelvis and was in oblique vertex presentation. The head was brought down into the incision and delivered easily as were the shoulders and body. The mouth and oropharynx were suctioned vigorously. The cord was clamped and cut. The infant was passed off to the waiting pediatrician in satisfactory condition. Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact. Uterus was explored and found to be empty. Uterus was delivered through the abdominal incision and massaged vigorously. Intravenous Pitocin was administered. T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis. Secondary running locking stitch was placed for extra strength to the wound. At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut. Intervening knuckle was excised and passed off the field. The proximal end of the tubal mucosa was cauterized. Cul-de-sac and gutters were suctioned vigorously. The uterus was returned to its proper anatomic position in the abdomen. The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl. Uterus was expressed of its contents. Patient was brought to the recovery room in satisfactory condition. There were no complications. There was 600 cc of blood loss. All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.surgery, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2762
}
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PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1. Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2. Arthrodesis, right second, third, and fourth toes with external rod fixation.,3. Hammertoe repair, right fifth toe.,4. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5. Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:, TIVA/local.,HISTORY:, This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion. The patient has a long history of crippling severe rheumatoid arthritis. She has pain with shoe gear and pain with every step. She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief. At this time, she desires attempted surgical reconstruction/correction. The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,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 and a safety strap was placed across her waist for her protection. Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril. Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique. 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 230 mmHg. The foot was lowered in the operative field. The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint. The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe. In addition, the range of motion was less than 5 degrees of the first ray. There was medial pinch callus and callus on the plantar right second metatarsal. Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length. Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon. Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery. Next, the medial and lateral wound margins were undermined with sharp dissection. The joint capsule was then visualized. Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule. A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade. The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint. In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal. Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head. A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare. Next, the bone was passed out as specimen. The head of the metatarsal had evidence of erosion and eburnation. The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue. This was hindering the range of motion of the joint and was removed. The fibular sesamoid was in the interspace. A lateral release was performed in addition. Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed. The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure. Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint. A small drill hole was made in the central aspect at the base of the proximal phalanx. The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline. A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position. It had an excellent fit and the range of motion again was markedly increased from the preoperative level. Next, the wound was again flushed with copious amounts of saline. The flexor tendon was inspected and was found to be intact plantarly. A #3-0 Vicryl was used to close the capsule in a running fashion. A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature. There was a clavus in the dorsal aspect of the head of the proximal phalanx noted. A linear incision was made over the proximal phalanx approximately 2 cm in length. The incision was deepened with #15 blade down to the subcutaneous tissue. Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint. The tendon was peeled off sharply, proximally, and distally. The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound. The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded. The base of the middle phalanx, however, had a normal-appearing cartilage. A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare. Next, the base of the middle phalanx was also resected. A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft. The toe assumed a straight and markedly increased straight position. An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed. The joint was flushed with copious amounts of saline. A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis. A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique. The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated. The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated. The same suture material was used. However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight. Next, attention was directed to the fifth digit, which was found to be contracted as well. A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length. A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected. The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound. A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare. The toe assumed to more rectus position. The reciprocating rasp was used to smooth the all bony surfaces. The joint was again flushed with saline. Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique. The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin. A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head. The incision was deepened with a #15 blade to the subcutaneous tissue. Any small vein traversing subcutaneous layer were ligated with electrocautery. Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively. Next, the dorsal linear capsular incision was made down to the bone with a #15 blade. The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound. Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly. A sagittal saw was used to resect all hypertrophic bone. A reciprocating rasp was used to smooth all bony surfaces. Next, the wound was flushed with copious amounts of saline. The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures. The skin was closed with #5-0 Monocryl in a running subcuticular fashion. The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl. Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated. Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon. The tendon was transected. Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed. Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position. One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds. Betadine-soaked Owen silk was applied to all wounds. Betadine-soaked 4 x 4 splints were applied to all toes. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. All the wires have previously been bent and cut and all were capped. A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact. She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c. She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office. She was given emergency contact numbers and standard postoperative instructions. She was given Darco OrthoWedge shoe and a pair of crutches. She was discharged in stable condition.nan
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{
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INDICATION: , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE: ,gastroenterology, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2764
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PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house. The patient states that she was knocked over by her friend's dog. She sustained a subcapital left hip fracture. Prior to admission, she lived alone in Terrano, was ambulating with a walker. All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE: ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained. She was then transferred from the preoperative care unit to operating suite #1. Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned. All bony prominences were well padded. She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards. The left lower extremity was then sterilely prepped and draped in the normal fashion. A skin maker was then used to mark all bony prominences. Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks. A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues. A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata. This was then incised utilizing Metzenbaum scissors. This was taken down to the bursa, which was removed utilizing a rongeur. Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched. The sciatic nerve was then visualized and retracted utilizing a Richardson retractor. Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule. The capsule was cleared and incised utilizing a T-shape incision. A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture. A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table. All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur. Acetabulum was then inspected and found to be clear. Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut. An oscillating saw was then used to make the femoral cut. Box osteotome was then used to remove the bone from proximal femur. A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position. Next, attention was turned to broaching. Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal. It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate. Next, the trial components were inserted consisting of the above-mentioned component sizes. The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip. It was noted that these size were stable through the range of motion. Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal. The femoral component was then inserted and then held under pressure. Extruding cement was removed from the proximal femur. After the cement had fully hardened and dried, the head and cup were applied. The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion. Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures. The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture. The wound was then copiously irrigated again to suction dry. Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures. The skin was then reapproximated utilizing skin clips. Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape. The patient was then transferred from the operating table to the gurney. Leg lengths were checked, which were noted to be equal and abduction pillow was placed. The patient was then transferred to the Postoperative Care Unit in stable condition.orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,
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{
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"dataset_name": "medical-transcription-4",
"id": 2765
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CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as "word salad" and "complete gibberish." She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of "word salad." When asked how he was, he replied: "abadeedleedlebadle." Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a "faucet dripping" as a "faucet drop." He called "red" "reed." Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to "1,200.",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997.neurology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2766
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CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES: ,Penicillin.,REVIEW OF SYSTEMS: ,The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:hematology - oncology, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
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PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.neurology, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,
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{
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"dataset_name": "medical-transcription-4",
"id": 2768
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EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2769
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The patient made some progress during therapy. She accomplished two and a half out of her five short-term therapy goals. We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits. The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently. The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect. She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently. Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect. The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9. Her last session occurred on 01/09/09. She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.speech - language, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: 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.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2770
}
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PROCEDURES:,1. Chest x-ray on admission, no acute finding, no interval change.,2. CT angiography, negative for pulmonary arterial embolism.,3. Nuclear myocardial perfusion scan, abnormal. Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2. Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3. Diabetes mellitus type 2.,4. Anemia, hemoglobin and hematocrit stable.,5. Hypokalemia, replaced.,6. History of coronary artery disease status post stent placement 2006-2008.,7. Bronchitis.,HOSPITAL COURSE: ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea. The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea. He was evaluated by Cardiology Dr. X, who proceeded with stress test. Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic. The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home. His hemoglobin on admission was 8.8, and has remained stable. He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1. Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2. Levaquin 750 mg p.o. daily for 5 more days.,3. Protonix 40 mg p.o. daily.,4. The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1. Recommend to follow up with Cardiology Dr. X's office in a week.,2. The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3. Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1. If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2. Discussed about discharge plan, instructions with the patient by bedside. He understands and agreed. Also discussed discharge plan instructions with the patient's nurse.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2771
}
|
PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:, This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain. On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis. However, the patient with additional history of loose stools for several days prior to event. Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy. She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach. The appendix itself noted to have a significant inflammation about it. There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:, The patient was placed in supine position. After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision. Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg. The Veress needle was then removed. A 10 mm trocar was then introduced through this incision into the abdomen. A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation. Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation. Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant. This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix. Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization. Through this port, the dissector was utilized to create a small window in the mesoappendix. Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix. Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples. Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure. Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it. The appendix was then removed from the 12 mm port site and taken off the surgical site. The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated. The base of the appendix was reevaluated and noted to be hemostatic. Aspiration of warm saline irrigant then done and noted to be clear. There was a small adhesion appreciated in the region of the surgical site. This was taken down with blunt dissection without difficulty. There was no evidence of other areas of disease. Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact. The instruments were removed from the patient and the port sites were then taken off under direct visualization. The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2. Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.surgery, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2772
}
|
HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity . , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. , ,MEDICATIONS: , Claritin for allergic rhinitis. , ,ALLERGIES: , None. , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft.consult - history and phy., return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2773
}
|
EXAM:, Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS: ,There are two small foci of increased activity in the left axilla. This is consistent with the sentinel lymph node. No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION: ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.hematology - oncology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2774
}
|
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.radiology, 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
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2775
}
|
REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma. He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07. He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. He is unable to stand at the moment. He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS: ,Keppra 1500 twice a day and Decadron 6 mg four times a day. His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:, On examination, he is lying on the stretcher. He has oxygen on and has periods of spontaneous hyperventilation. He is unable to lift his right arm or right leg. He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week. This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema. This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently. I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery. I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor. Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest. I discussed this both with him, although it is not clear to me how much he understood, as well as his family.consult - history and phy., seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2776
}
|
PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe. He is scheduled for the above-mentioned procedures. The planned procedures were discussed with the patient including the associated risks. The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia. He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark. Informed consent was obtained. The patient was then brought to the operating room and transferred to the operating table in supine position. Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm. The right upper extremity was then prepped and draped in the usual sterile fashion. Planned skin incision was marked along the base of the patient's right palm. Right upper extremity was then exsanguinated using Esmarch. The tourniquet was then inflated to 250 mmHg. Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision. Bleeding points were identified with electrocautery using bipolar electrocautery. Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision. Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band. Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed. This was confirmed by visually and palpably. Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision. Carpal canal was then inspected. The median nerve was flattened and injected. No other abnormalities were noted. Wounds were then irrigated with normal saline and antibiotic additive. Decadron 4 mg was then placed adjacent to the median nerve. Skin incision was then closed with interrupted 5-0 nylon suture. The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban. The tourniquet was then deflated. Attention was then directed to the left side. Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine. Band-Aid was then placed over the injection site. The patient was then awakened, extubated, and transferred over to his hospital bed. He was transported to recovery room in stable condition. There were no intraoperative or immediate postoperative complications. All counts were reported as correct.surgery, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2777
}
|
PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1. Anterior cruciate ligament rupture.,2. Medial meniscal tear.,3. Medial femoral chondromalacia.,4. Intraarticular loose bodies.,PROCEDURE PERFORMED:,1. Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2. Removal of loose bodies.,3. Medial femoral chondroplasty.,4. Medial meniscoplasty.,OPERATIVE PROCEDURE: ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia. Following this, the knee was sterilely prepped and draped as discussed for this procedure. The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region. After the notch was identified, then ACL was confirmed and ruptured. There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface. The snare was smoothed out. Entire area was thoroughly irrigated. Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage. The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing. There were multiple loose bodies noted in the knee and these were then __________ and then removed. The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed. The knee was taken through a full range of motion without any impingement. An Endobutton was used for proximal fixation. Distal fixation was obtained with an independent screw and a staple. The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,surgery, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2778
}
|
REASON FOR EXAM: , Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS: ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:, Moderate stenosis of aortic valve replacement. Mild mitral regurgitation. Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control. The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt. In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm. Multiple pictures obtained. Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level. Different pictures including short-axis views of the aortic valve was done. Extubation done with no problems and no blood on the probe. The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated. No masses or thrombi were seen. The left atrial appendage was free of thrombus. Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH. EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse. There was mild-to-moderate regurgitation on color flow interrogation. Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed. No perivalvular leak was noticed. There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve. Overall showed no abnormalities. The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable. No dissection.,IMPRESSION:,1. Mildly dilated left atrium.,2. Mild-to-moderate regurgitation.,3. Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis. Reevaluation in two to three years with transthoracic echocardiogram will be recommended.radiology, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2779
}
|
PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1. Normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of polyps. After signed informed consent, blood pressure monitoring, EKG monitoring, and pulse oximetry monitoring, he was brought to the Endoscopic Suite. He was given 100 mg of Demerol, 3 mg of Versed IV push slowly. Digital examination revealed a large prostate for which he is following up with his urologist. No nodules. 3+ BPH. Anorectal canal was within normal limits. No stricture tumor or ulcer. The Olympus CF 20L video endoscope was inserted per anus. The anorectal canal was visualized, was normal. The sigmoid, descending, splenic, and transverse showed scattered diverticula. The hepatic, ascending, cecum, and ileocecal valve was visualized and was normal. The colonoscope was removed. The air was aspirated. The patient was discharged with high-fiber, diverticular diet. Recheck colonoscopy three years.gastroenterology, digital examination, benign prostatic hypertrophy, anorectal canal, diverticular disease, photography, anorectal, colonoscopy,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2780
}
|
PREOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal fusion.,5. Two previous C-sections. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal effusion.,5. Two previous C-section. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6. Adhesions of bladder.,7. Poor fascia quality.,8. Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1. A repeat low transverse cervical cesarean section.,2. Lysis of adhesions.,3. Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4. The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:, 600 cc.,HISTORY AND INDICATIONS: ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus. The uterus appeared to be intact. This patient is a 26-year-old Caucasian female. The patient is well known to the OB/GYN clinic. The patient had two previous C-sections. She appears to be in probably early labor. She had an amniocentesis early today. She is contracting regularly about every three minutes. The contractions are painful and getting much more so since the amniocentesis. The patient had fetal lung maturity noted. The patient also has probable IUGR as none of her babies have been over 4 lb. The patient's baby appears to be somewhat small. The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound. The patient has had a spinal fusion, however, family planning is definitely complete per the patient. The patient refuses trial labor. The patient and I discussed the consent. She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery. Her questions were answered. The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy. The patient understands this and would like to try our best.,PROCEDURE: ,The patient was taken back to the operative suite. She was given general anesthetic by Department of Anesthesiology. Once again, in layman's terms, the patient understands the risks. The patient had the informed consent reviewed and understood. The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side. The patient had the first knife went through this incision. The second knife was used to go to the level of fascia. The fascia was very thin, ruddy in appearance, and with abundant scar tissue. The fascia was incised. Following this, we were able to see the peritoneum. There was really no obvious rectus abdominal muscles noted. They were very weak, atrophic, and thin. The patient has the peritoneum tented up. We entered the abdominal cavity. The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia. The bladder flap was then entered into the uterus as well. There are some bladder adhesions. We removed these adhesions and we removed the bladder of the fascia. We dissected the bladder of the lower segment. We made a small nick on the lower segment. We were able to utilize the blunt end of the knife to enter into the uterine cavity. The baby was in occiput transverse position with the ear being cocked at such a position as well. The patient's baby was delivered without difficulty. It was a 4 lb and 10 oz baby girl who vigorously cried well. There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection. The patient's placenta was delivered. There was no retained placenta. The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first. The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized. Then we ligated this as there was bleeding and oozing. The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc. The 400 cc was instilled. The bladder appears to be intact. The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment. There was some oozing around the area of the bladder. We placed an Avitene there. The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx. The patient has two clips on each side. There was excellent tubal occlusion and placement. The uterus was placed back into the abdominal cavity. We rechecked again. The tubal placement was excellent. It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx. The patient then underwent further examination. Hemostasis appeared to be good. The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia. We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible. The Scarpa's fascia was reapproximated with #0 gut. The skin was reapproximated then as well via subcutaneous closure. The patient's sponge and needle counts found to be correct. Uterus appeared to be normal prior to closure. Bladder appeared to be normal. The patient's blood loss is 600 cc.obstetrics / gynecology, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2781
}
|
PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage. A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures. The patient was agreeable to proceed.,OPERATIVE PROCEDURE: ,The patient was prepped and draped at the bedside over both chest tube sites. The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures. The skin was then cleansed and Vaseline occlusive dressing was applied over the sites. The same procedure was performed on the other side. The chest tubes were removed on full inspiration. Vital signs remained stable throughout the procedure. The patient will remain in the intensive care unit for continued monitoring.,cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2782
}
|
PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Uterine fibroids.,3. Pelvic pain.,4. Left adnexal mass.,5. Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Uterine fibroids.,3. Pelvic pain.,4. Left adnexal mass.,5. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Total abdominal hysterectomy (TAH).,2. Left salpingo-oophorectomy.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003. The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass. The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate. She was then prepared and draped in normal sterile fashion. A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel. The fascia was then incised in the midline. The fascial incision was then extended laterally with Mayo scissors. The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors. Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors. The rectus muscle was then separated in the midline. The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. The uterus and left adnexa were then palpated and brought out into the surgical field. The fundus of the uterus was grasped with a Lahey clamp. The GYN/Balfour retractor was placed. The bladder blade was placed. The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed. At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass. Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat. It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides. Next, the right ________ was isolated bluntly as the patient had a previous RSO. This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch. Attention was then turned to the left round ligament, which was tented up with the Babcock. Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums. The left infundibulopelvic ligament was then bluntly isolated. It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch. The bladder flap was then placed on tension with Allis clamps. It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians. It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec. The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture. The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps. These were then transected and suture ligated with #0 Vicryl suture. The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible. It was then entered with the last transection. The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors. The angles of the vaginal cuff were then grasped with Kocher clamps. A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed. Good hemostasis was appreciated. A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl. This was tagged for later use. The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture. The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place. The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated. The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion. The GYN/Balfour retractor and bladder blade were then removed. The bowel was then packed. Again copious suction irrigation was performed with hemostasis appreciated. The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion. The fascia was then reapproximated with #0 Vicryl suture in a running fashion. The Scarpa's fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion. Steri-Strips were placed. At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally. The patient tolerated the procedure well and was taken to Recovery in stable condition. Sponge, lap, and needle counts were correct x2. Specimens include uterus, cervix, left fallopian tube, and ovary.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2783
}
|
EXAM:, Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:, Tiny cluster of calcifications at the 11:30 position of the right breast. Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,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 Second Look Software Version 7.2 was utilized.radiology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2784
}
|
SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, she does not use oxygen at her independent assisted living home. Yesterday, she had made improvement since being here at the hospital. She needed oxygen. She was tested for home O2 and qualified for it yesterday also. Her lungs were very tight. She did have wheezes bilaterally and rhonchi on the right side mostly. She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room. She stated that she needed to urinate. She awoke, decided not to call for assistance. She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker. She attempted to walk to the rest room on her own. She sustained a fall. She stated that she just felt weak. She bumped her knee and her elbow. She had femur x-rays, knee x-rays also. There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side. This morning, she denied any headache, back pain or neck pain. She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS: The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106. She is 95% on 2 L via nasal cannula.,HEART: Regular rate and rhythm without murmur, gallop or rub.,LUNGS: Reveal no expiratory wheezing throughout. She does have some rhonchi on the right mid base. She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN: Soft and nontender. Her bowel sounds x4 are normoactive.,NEUROLOGIC: She is alert and oriented x3. Her pupils are equal and reactive. She has got a good head and facial muscle strength. Her tongue is midline. She has got clear speech. Her extraocular motions are intact. Her spine is nontender on palpation from neck to lumbar spine. She has good range of motion with regard to her shoulders, elbows, wrists and fingers. Her grip strengths are equal bilaterally. Both elbows are strong from extension to flexion. Her hip flexors and extenders are also strong and equal bilaterally. Extension and flexion of the knee bilaterally and ankles also are strong. Palpation of her right knee reveals no crepitus. She does have suprapatellar inflammation with some ecchymosis and swelling. She has got good joint range of motion however.,SKIN: She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1. Acute on chronic COPD exacerbation.,2. Community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.,3. Generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1. I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker. Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2. We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.cardiovascular / pulmonary, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2785
}
|
OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other. The ear infection itself is not contagious but the respiratory infection preceding it is transmittable. Otitis media is most often seen in infants and young children. There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture. Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,* Irritability.,* Ear pain, fullness, hearing loss.,* Infants may pull on ear.,* Fever.,* Vomiting.,* Discharge from ear.,* Diarrhea.,TREATMENT:,* Diagnosis is by physical exam and otoscopic exam. Sometimes fluid from the ear is cultured.,* Pain relievers, like acetaminophen (Tylenol). Infant pain relievers are available.,* Decongestant to relieve symptoms of upper respiratory tract infection.,* Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin. Finish ALL antibiotics as prescribed. Do not stop the medication even if symptoms subside.,* Avoid swimming until infection goes away.,* Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,* Surgery to remove adenoids if they are enlarged.,* Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.ent - otolaryngology, ear, ear infection, otitis media, sinuses, drainage, ear pain, fullness, hearing loss, ear swelling, fever, bacterial infection, eustachian tubes, infection, eardrum, respiratory, otitis, media, eustachian, tubes,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2786
}
|
PROCEDURE:, Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat. The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat. The antebrachial fascia was cut proximally under direct vision with a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl. Care was taken to avoid entrapping the motor branch of the median nerve in the suture. A hemostat was placed under the repair to ensure that the median nerve was not compressed. The skin was repaired with 5-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted. The patient was sent to the recovery room in good condition, having tolerated the procedure well.orthopedic, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2787
}
|
REASON FOR VISIT:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities.,MEDICATIONS: ,1. Fosamax - 70 mg weekly.,2. Lisinopril - 20 mg daily.,3. Metformin - 850 mg daily.,4. Amlodipine - 5 mg daily.,5. Metoprolol - 150 mg twice daily.,6. Warfarin - 5 mg daily.,7. Furosemide - none.,8. Potassium - none.,9. Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES: ,1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2. Heart failure and she needs more diuretic.,3. High blood pressure controlled.,4. Hyperlipidemia.,5. Diabetes mellitus type 2.,6. Nonspecific intraventricular conduction delay.,7. History of alcohol abuse.,8. Osteoporosis.,9. Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2788
}
|
SUBJECTIVE:, I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change. What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. The staff reports to me that her appetite is good and that she is eating as well as ever. I talked to Anna today. She feels a little fatigued. Otherwise, she is doing well.,PHYSICAL EXAMINATION: ,Vitals as in the chart. The patient is a pleasant and cooperative. She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning. To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning. She will get 55 units in the morning. I am also decreasing once again her Humalog sliding scale insulin prior to meals. I will review the blood glucoses again next week.,soap / chart / progress notes, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2789
}
|
CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS: ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days. He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS: ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. HEENT: PERRLA. EOMI. Conjunctivae anicteric. Skull is normocephalic. He is not complaining of bruising. HEENT: TMs and canals are normal. There is no Battle sign. NECK: Supple. He has good range of motion. Spinal processes are normal to palpation. LUNGS: Clear. CARDIAC: Regular rate. No murmurs or rubs. EXTREMITIES: Left elbow is tender. He does not wish to move it at all. Shoulder and clavicle are within normal limits. Wrist is normal to inspection. He does have some pain to palpation. Hand has good capillary refill. He seems to have decreased sensation in all three dermatomes. He has moderately good abduction of all fingers. He has moderate opponens strength with his thumb. He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow. He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length. The proximal part looks like it is in good position. The distal part has about 6 mm of displacement. There is no significant angulation. The joint itself appears to be intact. The fracture line ends where it appears above the joint. I do not see any extra blood in the joint. I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X. He suggests we go ahead and splint him up and he will follow the patient up. At this point, it does not seem like there needs to be any surgical revision. The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied. There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go. Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with. They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1. Fracture of the humerus, spiral.,2. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3. Psychiatric disorder, unspecified.,DISPOSITION: The patient will follow up as mentioned above. They can return here anytime as needed.
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2790
}
|
REASON FOR CONSULT:, Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY: ,The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room. Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma. The patient since the morning has improved, but still not completely back to the baseline. Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:, History of IgG subtype multiple myeloma.,SURGICAL HISTORY:, Nothing significant.,PSYCHIATRIC HISTORY: ,Nothing significant.,SOCIAL HISTORY: ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS: ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness. The patient himself is not able to give any history only source is the chart. For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5. The patient on supplemental oxygen was FiO2 on 2 L 96%. Limited physical examination.,HEENT: Head, normocephalic and atraumatic. Throat clear. No discharge from the ear and the nose. No discoloration of conjunctivae and the sclerae.,NECK: Supple. No signs of any meningismus. Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion. No bruit auscultated over the neck and the orbits.,LUNGS: Clear to auscultation.,HEART: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis. No rash. No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC: Examination is limited. Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented. Cranial nerve examination limited, but apparently nonfocal. Motor examination is very limited except for the grips, which were strong enough. I was not able to obtain much. Deep tendon reflexes were not reliable. Toes equivocal and downgoing. Sensory examination is not reliable, though intact for painful stimuli with limited examination. Coordination could not be tested. Gait could not be tested.,IMPRESSION:, History of multiple myeloma and altered mental status in multiple myeloma setting. Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management. I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection. No other intervention at this time. The patient may be started on aspirin, if it is okay with Dr. X.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2791
}
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PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was prepped and draped in the usual fashion. A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade. This was beveled anteriorly in a lamellar fashion using the crescent knife. Then the anterior chamber was entered with a slit knife. The chamber was deepened with Viscoat. Then a paracentesis at the 3 o'clock position was created using a super sharp blade. A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps. Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves. Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified. I/A proceeded without difficulty using the irrigation/aspiration cannula. The capsule was felt to be clear and intact. The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded. A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture. Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally. Maxitrol ointment was instilled into the conjunctival sac. The eye was covered with a double patch and shield, and the patient was discharged.surgery, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2792
}
|
PROCEDURE: , Skin biopsy, scalp mole.,INDICATION: ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1. K-Y jelly.,2. Betadine prep locally.,3. A 1% lidocaine with epinephrine local instilled.,4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.,IMPRESSION:, Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2793
}
|
TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child. He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract. He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained. All questions were answered. The patient was brought to preoperative holding area where the operative right eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced by the anesthesia service. A time-out was called to confirm the procedure and operative eye. The right operative eye was disinfected and draped in a standard fashion for eye surgery. A lid speculum was placed. The vitreoretinal team placed the infusion cannula after performing a peritomy. At this point in the case, the patient was turned over to the cornea service with Mrs. Jun. A paracentesis was made at the approximately 3 o'clock position. Healon was placed into the anterior chamber. The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis. This incision was then shelved anteriorly and used to enter the anterior chamber. The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome. Hydrodissection was performed. The lens nucleus was removed using phacoemulsification and irrigation and aspiration. Lens cortex also was removed using irrigation and aspiration. Viscoelastic was placed to inflate the capsular remnant. The diamond knife was used to enlarge the phaco incision. Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty. The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed. The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber. This was done without difficulty. The anterior chamber was secured and watertight at the end of the procedure. Intraocular pressure was satisfactory. The patient tolerated the procedure well and then was turned over to the retina service in good condition. They will dictate a separate note.ophthalmology, phacoemulsification, intraocular lens implant, posterior chamber, chamber, eye, intraocular, lens,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2794
}
|
PREOPERATIVE DIAGNOSIS:, Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2. 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1. Repair of nerve and tendon, right ring finger.,2. Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME: ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION: ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle. The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well. The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room and placed in the supine position. All bony prominences were adequately padded. Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time. The right upper extremity was prepped and draped in the usual sterile fashion. The hand was inspected. Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture. The sutures were removed and the wound was explored. It was found that the ulnar digital neurovascular bundle was 100% transected. The radial neurovascular bundle on the right ring finger was found to be completely intact. We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP. We copiously irrigated the wound. Repair was undertaken of the FDS with #3-0 undyed Ethibond suture. The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact. Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair. Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury. The digital nerve was dissected proximally and distally to likely visualize the nerve. The nerve was then approximated using microvascular technique with #8-0 nylon suture. The hands were well approximated. The nerve was not under undue tension. The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture. Sterile dressing was placed and a dorsal extension Box splint was placed. The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition. Overall prognosis is good.surgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2795
}
|
EXAM:, Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:, Most recently obtained mm/dd/yy.,FINDINGS:, The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm. The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus. There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1. No evidence of hydronephrosis.,2. Mass within the right lobe of the liver. The patient apparently has a severe iodine allergy. Further evaluation with MRI is recommended.,3. The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,radiology, lobe of the liver, status post cystectomy, renal ultrasound, renal failure, neurogenic bladder, bladder status, neurogenic, bladder, cystectomy, hydronephrosis, lobe, liver, ultrasound, mass, renal, kidneys/renal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2796
}
|
HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improvement of her symptoms. The nursing home did not do a voiding diary. She is accompanied by her power of attorney. No dysuria, gross hematuria, fever or chills. No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION: ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. This has not improved on VESIcare as well as Enablex. Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure. The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today. Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided. They will see Dr. X with a prior voiding diary, which is again discussed. All questions answered.,PLAN:, As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney. In the meantime, Sanctura prescription is provided, and voiding diaries are provided. All questions answered.urology, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2797
}
|
PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE: ,The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in routine fashion. An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively. Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter. Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1. LV is normal in size and shape with good contractility, EF of 60%.,2. LMCA normal.,3. LAD has 20% to 30% stenosis at the origin.,4. LCX is normal.,5. RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise. Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. Follow up in the clinic.surgery, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2798
}
|
DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 2799
}
|
PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. Her hemolysis seemed to slow down. She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen. Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital. She had a blood culture, which was also negative. She was empirically started on presentation with the cefotaxime intravenously. Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics. After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present. She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures. The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression. Questions were answered to their satisfaction. They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained. She was then given Versed 1 mg intravenously by myself. She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied. She was then given 20 mcg of fentanyl intravenously by myself. She was placed in the left lateral decubitus position. Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution. She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision. Clear fluid was not obtained initially, needle was withdrawn intact. The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained. The stylette was replaced and the needle was withdrawn intact and bandage was applied. Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable. Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.neurology, moderate sedation, lumbar puncture, needle, lumbar,
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