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"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3200
}
|
PREOPERATIVE DIAGNOSES:, Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES: ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007. The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:, The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department. The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation. Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision. The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed. The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection. Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end. A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized. Adequate hemostasis was noted. This tube was placed back in its anatomic position. The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position. The peritoneum as well as fascia was reapproximated with 0-Vicryl. The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch. Pressure dressings were applied. Marcaine 10 mL was used prior to making an incision. Sterile dressing was applied. The large mole-like lesion was grasped with Allis. It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied. Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.obstetrics / gynecology, sterilization, fallopian tube, tubal ligation, postpartum
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3201
}
|
HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia.,PAST MEDICAL HISTORY:, Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.,FAMILY HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:,GENERAL: This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.,HEENT: Funduscopic examination normal. He has oral thrush.,LYMPH: He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK: No goiter, no jugular venous distention.,CHEST: Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART: Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN: Soft and nontender.,GENITOURINARY: Normal.,RECTAL: Unremarkable.,SKIN: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2. Thrush.,3. Elevated unconjugated bilirubins.,4. Hepatitis.,5. Elevated globulin fraction.,6. Renal insufficiency.,7. Subcutaneous nodules.,8. Risky sexual behavior in 1982 in Haiti.,PLAN:,1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2. Begin intravenous Bactrim and erythromycin.,3. Begin prednisone.,4. Oxygen.,5. Nystatin swish and swallow.,6. Dermatologic biopsy of lesions.,7. Check HIV and RPR.,8. Administer Pneumovax, tetanus shot and Heptavax if indicated.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3202
}
|
PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion. A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory. A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly. This was then carefully checked for symmetry and appeared to be satisfactory. All marks were then completed and lightly incised on both breasts. The right breast was approached first. The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery. After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately. This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle. There was very little bleeding with this procedure. After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus. Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket. After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast. Hemostasis was obtained with electrocautery. After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps. On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified. This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology. After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues. The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner. After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area. After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left. Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated. The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached. The nipple was sutured with running intradermal 4-0 Monocryl. Vascularity appeared good throughout. After this had been completed, all wounds were cleaned and Steri-Stripped. The patient tolerated the procedure well. All counts were correct. Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition.cosmetic / plastic surgery, macromastia, estimated blood loss, monocryl, steri-stripped, dermis, inferior breast, mammoplasty, neo-nipple, prepped and draped, ptotic breasts, recovery room in good condition, reduction mammoplasty, superior breast, upright position, bilateral macromastia, incision, superiorly, breasts
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3203
}
|
HISTORY OF PRESENT ILLNESS:, This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant. The patient did well after the liver transplant and the only problems started:,1. History of food allergies.,2. History of dental cavities.,At this time, the patient came for a followup and is complaining of a left upper molar pain. There are no other complaints.,DIET: , Lactose-limited diet.,MEDICATIONS: , Please see the MRC form.,ALLERGIES: , There are no allergies.,SOCIAL HISTORY:, The patient lives with the parents in Lindsay, California and has a good environment.,FAMILY HISTORY: , Negative for gastrointestinal illness except that a sibling has ulcerative colitis.,REVIEW OF SYSTEMS: , The system review was only positive for molar pain, but rest of the 13 review of systems were negative to date.,PHYSICAL EXAMINATION: ,MEASUREMENTS: Height 135 cm and weight 28.1 kg.,VITAL SIGNS: Temperature 98.9 and blood pressure 105/57.,GENERAL: A well-developed, well-nourished child in no acute distress.,HEENT: Atraumatic and normocephalic. The pupils are equal, round, and reactive to light. Full EOMs. The conjunctivae and sclerae are clear. The TMs show normal landmarks. The nasal mucosa is pink and moist. The teeth and gums are in good condition. The pharynx is clear.,NECK: Supple, without thyromegaly and without masses.,LYMPHATIC: No adenopathy.,LUNGS: Clear to auscultation, with no retractions.,CORONARY: Regular rhythm without murmur. S1 and S2 are normal. The pulses are full and symmetrical bilaterally.,ABDOMEN: Normal bowel sounds. No hepatosplenomegaly, no masses, and no tenderness.,GENITALIA: Normal female by inspection.,SKIN: No unusual lesions.,BACK: No scoliosis, hairy patch, lipoma, or sacral dimple.,EXTREMITIES: No cyanosis, clubbing, or edema.,CENTRAL NERVOUS SYSTEM: Developmentally appropriate for age. DTRs are 2+ and symmetrical. The toes are downgoing bilaterally. Motor and sensory without asymmetry. Cranial nerves II through XII are grossly intact.,LABORATORY DATA:, Laboratory data from 12/30/2007 tacrolimus 3.1 and negative Epstein-Barr, CMV was not detected.,FINAL IMPRESSION:, This is a 10-year-old with history of:,1. Biliary atresia.,2. Status post orthotopic liver transplantation.,3. Dental cavities.,4. Food allergies.,5. History of urinary tract infections.,PLAN: , Our plan would be to continue with the medications as follows:,1. Prograf 0.5 mg p.o. b.i.d.,2. Valganciclovir 420 mg p.o. b.i.d.,3. Labs every 2 to 3 months.,4. To return to clinic in 4 months.,5. To refer this patient to a pediatric dentist for assessment of the dental cavities.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3204
}
|
GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD): (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3205
}
|
PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week.orthopedic, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3206
}
|
TITLE OF OPERATION:,1. Pars plana vitrectomy.,2. Pars plana lensectomy.,3. Exploration of exit wound.,4. Closure of perforating corneal scleral laceration involving uveal tissue.,5. Air-fluid exchange.,6. C3F8 gas.,7. Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall. He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:, General.,SPECIMEN:, None.,IMPLANTS:,1. Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2. Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife. All of their questions were answered. Informed consent was signed. The patient was brought into the operating room. A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye. After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery. A wire lid speculum was used to separate the eyelids of the left eye. A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon. The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried. A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors. Hemostasis was achieved with bipolar cautery. A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant. A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture. The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion. Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule. The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter. The vitreous was trimmed to the vitreous base. A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course. The exit wound was explored. No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps. The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression. No retinal breaks or defects were noted in the periphery. The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees. Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve. The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion. The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures. A 12% concentration of C3F8 gas was flushed through the eye. The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture. All of the sclerotomies were noted to be airtight. The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried. Subconjunctival injections of Ancef and Decadron were delivered inferotemporally. The lid speculum was removed. Pred-G ointment and atropine solution were applied to the ocular surface. The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well. There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3207
}
|
PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:, Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1. Nasal endoscopy.,2. Partial rhinectomy.,ANESTHESIA:, General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago. He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall. He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip. He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma. The preoperative examination shows induration of the nasal tip without significant erythema. There is focal tenderness just cephalad to the alar crease. There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position. Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin. He was prepped and draped in standard fashion. The left nasal cavity was examined by anterior rhinoscopy. The septum was midline. There was slight asymmetry of the nares. No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor. The 0-degree nasal endoscope was then used to examine the nasal cavity more completely. No lesion was detectable. A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A. The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present. Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section. A diagnosis of diffuse invasive squamous cell carcinoma was rendered. An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery. The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin. The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it. Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins. Additional soft tissue was then taken from all margins tagging them for the pathologist. The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone. A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone. Additional soft tissue was taken in these regions along the superior margin. The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology. Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound. A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla. This was all submitted to pathology for routine permanent examination. Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture. The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well. Sponge and needle counts were correct.ent - otolaryngology, nasal cavity, joseph elevator, squamous cell carcinoma, endoscopy, intranasally, maxilla, nasal ala, nasal tip, rhinectomy, septorhinoplasty, nasal endoscopy, lateral cartilage, frozen section, additional soft, squamous cell, cell carcinoma, nasal, cartilage, squamous, carcinoma, cavity, tissue
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3208
}
|
PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia. A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position. An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided. Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen. A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities. Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly. Several minutes of compression was used for hemostasis. Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side. Also, an incision was made in the level of the knee and the saphenous vein was isolated there. The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis. Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us. Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg. The stab phlebectomies were performed with a hook and they were very satisfactory. Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL. The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.neurology, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3209
}
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CHIEF COMPLAINT: ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:, Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has a history of gastroparesis and impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan. , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head. Was not wearing a helmet. Reports that he did not go to the emergency room and had a headache for several days after this incident. Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room. Patient did not comply. Reports that the headache has resolved. Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN. Slender, 34-year-old white male. VITAL SIGNS: Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. Microalbumin 100. SKIN: There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. No signs of infection. Wound is closed with new granulation tissue. Appears to be healing well. HEENT: Normocephalic. PERRLA. EOMI. TMs pearly gray with landmarks present. Nares patent. Throat with no redness or swelling. Nontender sinuses. NECK: Supple. Full ROM. No LAD. CARDIAC:endocrinology, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3210
}
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PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:, Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:, Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly. Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine. An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible. No purulent drainage was obtained. The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture. Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19. The area did not drain any purulent material. The carious tooth #19 was then extracted by elevator and forceps extraction. After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture. The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction. After the extraction, the throat pack was removed. An orogastric tube was then placed by Dr. X, and stomach contents were suctioned. The pharynx was then suctioned with the Yankauer suction. The patient was awakened, extubated, and taken to the PACU in stable condition.surgery, yankauer suction, orogastric tube, carious teeth, penrose drain, forceps extraction, dental abscess, incision, elevator, mandibular, dental, abscess, teeth, intraoral, extraction, drainage,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3211
}
|
PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1. Anterior cervical discectomy of C3-C4.,2. Removal of herniated disc and osteophytes.,3. Bilateral C4 nerve root decompression.,4. Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. Grafting of fibular allograft bone for creation of arthrodesis.,6. Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain. Conservative therapy has failed to improve the problem. Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck. Dissection was carried down through the platysmal musculature and the anterior spine was exposed. The medial borders of the longus colli muscles were dissected free from their attachments to the spine. A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space. Castoff self-retaining pins were placed into the body of the C3 and C4. Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed. Quite a bit of overhanging osteophytes were identified and removed. As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs. A high-speed diamond bur was used to slowly drill these spurs away. I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen. The dura was extremely thin and I could see through it in several areas. I removed the bony compression in the foramen and identified soft tissue and veins overlying the root. All of these were not stripped away for fear of tearing this very tissue-paper-thin dura. However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis. As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally. Under distraction the graft was placed and fit well. An x-ray showed good graft placement.,Attention was turned to spinal instrumentation. A Synthes Short Stature plate was used with four 3-mm screws. Holes were drilled with all four screws were placed with pretty good purchase. Next, the locking screws were then applied. An x-ray was obtained which showed good placement of graft, plate, and screws. The upper screws were near the upper endplate of C3. The C3 vertebral body that remained was narrow after drilling off the spurs. Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure. A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied along with a rigid Philadelphia collar. The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.neurosurgery, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3212
}
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HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%. FEV1 was 45%. FEV1/FVC ratio was 52%. The predicted was 67%. FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator. SVC was 91%. Inspiratory capacity was 70%. Residual volume was 225% of its predicted. Total lung capacity was 128%. ,IMPRESSION:,1. Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2. Probably there is some restrictive element because of fibrosis. The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3. Diffusion capacity was not measured. The flow volume loop was consistent with the above.,cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3213
}
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HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:, No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:, No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.office notes, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3214
}
|
PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:, Left undescended testis plus left inguinal hernia.,PROCEDURES:, Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:, A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:, Sponge and needle counts were correct x2.,SPECIMENS,: No tissues sent to Pathology.,ANESTHESIA:, General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left. The plan is for repair.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped. A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue. We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring. We were able to dissect all the way up to the ring, but were unable to get the testis delivered. We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia. The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors. The testis itself was quite high up in the upper canal. We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors. Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture. We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length. We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off. We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum. The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch. The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture. The testis was then placed into the scrotum in the proper orientation. We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well. We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure. The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure. Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure. The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.surgery, inguinal hernia repair, ilioinguinal nerve block, external oblique fascia, hernia repair, epididymal attachment, external ring, inguinal incision, scarpa fascia, cord length, inguinal hernia, nerve block, ilioinguinal nerve, undescended testis, testis, inguinal, fascia, hernia, dissected,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3215
}
|
Inguinal hernia hydrocele repair.surgery, inguinal hernia, external oblique, hernia sac, hydrocele, hydrocele repair, ilioinguinal nerve, inguinal skin crease, oblique aponeurosis, scrotum, spermatic cord, testicle appendix, transverse inguinal skin crease incision, hernia, anesthesia, inguinalNOTE,: 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": 3216
}
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PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:, Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair. The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right. The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced. The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:, After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion. An infraumbilical incision was made with a #15 Bard-Parker scalpel. The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty. Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg. Next, the Veress was removed and #10 bladed trocar was inserted without difficulty. The 30-degree camera laparoscope was then inserted and the abdomen was explored. There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible. Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus. Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization. A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization. Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral. The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty. Dissection was carried out, freeing up the hernia sac from the peritoneum. This was done without difficulty reducing the hernia in its entirety. Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract. The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples. This was done without difficulty. All three ports were removed under direct visualization. No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle. Skin was closed with running subcuticular #4-0 undyed Vicryl. Steri-Strips and sterile dressings were applied. Attention was next made to carrying out the circumcision. The foreskin was retracted back over the penis head. The desired amount of removing foreskin was marked out with a skin marker. The foreskin was then put on tension using a clamp to protect the penis head. A #15 blade scalpel was used to remove the foreskin and sending off as specimen. This was done without difficulty. Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially. This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing. The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.urology, herniorrhaphy with mesh, laparoscopic, blunt dissector, inguinal herniorrhaphy, inguinal hernia, hernia, inguinal, peritoneum, circumcision, phimosis, foreskin
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3217
}
|
There is normal and symmetrical filling of the caliceal system. Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally. The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:, Negative intravenous urogram.,radiology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: 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": 3218
}
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PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding history of foot problems. The problem has been progressive in nature. The preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed. The patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered. The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity. The purpose of the surgery is to alleviate pain and discomfort.,DETAILS OF PROCEDURE: ,The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure. The patient was brought to the operating room and placed in the supine position. No tourniquet was utilized. IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. The lower extremity was prepped and draped in the usual sterile manner. Balanced anesthesia was obtained.,PROCEDURE:, Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot. A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal. Care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery. The extensor tendon was identified and retracted medially. Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer. A linear periosteal capsular incision was made in line with the skin incision. The capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface. Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head. An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration. The both edges were rasped smooth.,Attention was then focused on the fifth metatarsal. The periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface. An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,Using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal. Generous amounts of lateral cortex were preserved for the lateral hinge. The wedge was removed from the surgical field. The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position. Good purchase was noted at the osteotomy site. Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position. The surgical site was flushed with copious amounts of normal saline irrigation. The periosteal and capsular layers were closed with running sutures of 3-0 Vicryl. The subcutaneous tissues were closed with 4-0 Vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion. A dressing consisting of Adaptic, 4 x 4, confirming bandages, and ACE wrap to provide mild compression was applied. The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,A walker boot was dispensed and applied. The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,Office visit will be in 4 days. The patient was given prescriptions for Keflex 500 mg one p.o. t.i.d. for 10 days and Ultram ER, #15 one p.o. daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises.,After short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.orthopedic, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3219
}
|
Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid. ,PLAN: ,Planned for electronystagmography to document the degree of vestibular hypofunction.,consult - history and phy., electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3220
}
|
PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position. Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy. An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold. A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle. 200 cc was infiltrated on each side. This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula. This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position. This would result in an elevation of the nipple-areolar complex with transposition. The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle. Hemostasis was achieved with electrocautery. After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple. Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture. Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing. The patient tolerated the procedure well. The patient was returned to recovery room in satisfactory condition.cosmetic / plastic surgery, breast ptosis, dermabond, mammary hypertrophy, monocryl, anesthesia, breast tissue, endotracheal anesthesia, lipectomy, mastopexies, mastopexy, nipple, nipple-areolar complex, suction assisted lipectomy, nipple areolar complex, lactated ringers, nipple areolar, areolar complex, epithelialization, areolar, breast,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3221
}
|
PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:, 1.5 x 2.9 cm,POSTOP SIZE:, 2.7 x 2.9 cm,INDICATION:, Poorly defined borders.,COMPLICATIONS:, None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:, Simple Linear Closure.,DESCRIPTION OF PROCEDURE:, Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.dermatology, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3222
}
|
PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:, Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED: ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS: ,50 mL.,NEEDLE AND SPONGE COUNT:, Correct.,SPECIMENS: , None.,TOURNIQUET TIME: ,Approximately 77 minutes.,IMPLANTS USED:,1. Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2. All-poly patella, size 32/8.5 mm thickness.,3. Prolong highly cross-linked polyethylene 12 mm.,4. Stemmed tibial component, size 2.,5. Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability. Surgery was indicated to relieve her pain and improve her functional ability. Goal objectives and the procedure were discussed with the patient. Risks and benefits were explained. No guarantees have been made or implied. Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE: ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion. A nonsterile tourniquet was placed proximally in the thigh. Antibiotics were infused prior to Foley catheter insertion. Time-out procedure was called.,A straight longitudinal anterior midline incision was made. Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia. Deep fascia was exposed. The tourniquet was inflated at 300 mmHg prior to the skin incision. A standard medial parapatellar approach was made. The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion. Incision was then carried down distally and distal arthrotomy was completed. Patellar tendon was well protected. Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair. The knee was exposed very well. Significant tricompartmental osteoarthritis was noted. The osteophytes were removed with a rongeur. Anterior and posterior cruciate ligaments were excised. Medial and lateral meniscectomies were performed. Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity. The medial compartment was more affected than lateral. Medial ligaments were tied. Retropatellar fat pad was excised. Osteophytes were removed. Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur. The trochlear notch was ossified. A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment. The anterior portal was 1 cm anterior to the PCL attachment. The anterior femoral sizer was positioned keeping 3 degrees of external rotation. Rotation was also verified using the transepicondylar axis and Whiteside line. The pins were positioned in the appropriate holes. Anterior femoral cut was performed after placing the cutting guide. Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned. A distal femoral cut was made which was satisfactory. A sizer was positioned which was noted to be D. The 5-in-1 cutting block size D was secured with spring pins over the resected bone. Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer. Then using a reciprocating saw, intercondylar base notch cut and side cuts were made. Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle. Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed. The bone with its attached soft tissue was removed. Once the femoral preparation was completed, attention was placed for the preparation of the tibia. The medial and the lateral collateral ligaments were well protected with a retractor. The PCL retractor was positioned and the tibia was translated anteriorly. Osteophytes were removed. The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle. Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe. Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest. A built-in 7-degree posterior slope was considered with instrumentation. Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site. Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane. The resected thickness of the bone was satisfactory taken 2 mm from the most affected site. The resected surface shows some sclerotic bone medially. Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle. Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed. Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion. Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension. The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia. Size 2 tibial trial plate was positioned. Appropriate external rotation was maintained with the help of the horseshoe alignment rod. Reference to the tibial crest distally and 2nd toe was considered as before. The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle. The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor. At this point, trial femoral and tibial components were reduced using a 12 mm trial liner. The range of motion and stability in both flexion and extension was satisfactory. No further soft tissue release was indicated. I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella. Using a patellar caliper, the thickness was measured to be 21.5 mm. This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact. Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide. Using a caliper, the resected patella was measured, which was noted to be 13 mm. A 32 sizer was noted to accommodate the resected surface very well. Drilling was completed and trial 32 button was inserted without any difficulty. The tracking was satisfactory. There was no evidence of any subluxation or dislocation of the patella. The trial components position was satisfactory. The alignment and the rotation of all 3 components were satisfactory. All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system. The resected surfaces were dried with a sponge. Two batches of Palacos cement were mixed. The cementing was initiated starting with tibia followed by femur and patella. Excess peripheral cement were removed with the curette and knife. The knee was positioned in extension with a 12 mm trial liner. Patellar clamp was placed after cementing the all-poly patella. Once the cement was set hard and cured, tourniquet was deflated. Hemostasis was achieved. The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner. Range of motion and stability was verified at 0 degrees and flexion of 120 degrees. Anterior-posterior drawer test was satisfactory. Medial and lateral stability was satisfactory. Patellar tracking was satisfactory. The wound was thoroughly irrigated. Hemostasis was achieved. A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine. The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion. The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally. The skin was approximated with staples. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient was then transferred to the recovery room in a stable condition. There were no intraoperative complications noted. She tolerated the procedure very well.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3223
}
|
CHIEF COMPLAINT: ,This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity: The severity has worsened over the past 3 months. Timing (onset/frequency): Onset was gradual and after pitching a baseball game. Modifying Factors: Patient's condition is aggravated by throwing. He participates with difficulty in basketball. Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY: ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:, No previous surgeries.,FAMILY HISTORY:, Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam: BP Standing: 116/68 Resp: 16 HR: 68 Temp: 98.1 Height: 5 ft. 11 in. Weight: 165 lbs. Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Oriented to person, place and time. Right shoulder shows evidence of swelling and tenderness. Radial pulses are 2 /4, bilateral. Brachial pulses are 2 /4, bilateral.,Appearance: Normal.,Tenderness: Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion: Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation. L shoulder normal.,Strength: External rotation - fair. Internal rotation - poor right.,AC Joint: Pain with ABD and cross-chest - mild right.,Rotator Cuff: Impingement - moderate. Painful arc - moderate right.,Instability: None.,TEST & X-RAY RESULTS:, X-rays of the shoulder were performed. X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed. I noted that this is a very common condition resulting in significant difficulties with use of the arm. Several treatment options and their potential benefits were described. Nonsteroidal anti-inflammatories can be helpful but typically are slow acting. Cortisone shots can be very effective and are quite safe. Often more than one injection may be required. Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength. If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear. Injected shoulder joint and with Celestone Soluspan 1.0 cc . Ordered x-rays of shoulder right.,PRESCRIPTIONS:, Vioxx Dosage: 25 mg tablet Sig: TID Dispense: 60 Refills: 0 Allow Generic: Yes,PATIENT INSTRUCTIONS:, Patient was instructed to restrict activity. Patient was given instructions on RICE therapy.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3224
}
|
REASON FOR CONSULTATION:, Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:, Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. Her hemoglobin was 13.3 with white count of 11.8 at that time. Her lymphocyte count was 6.7. The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000. She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes. Platelet count was 38. Her rapid strep screen was negative but the infectious mononucleosis screen is positive. The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May. She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that. The patient continues to have sore throat.,She denies any history of epistaxis. Denies any history of gum bleeding. The patient denies any history of petechiae. She denies any history of abnormal bleeding. Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:, Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional: The history of fever about 2 weeks ago.,HEENT: Complains of some difficulty in swallowing.,Cardiovascular: Negative.,Respiratory: Negative.,Gastrointestinal: No nausea, vomiting, or abdominal pain.,Genitourinary: No dysuria or hematuria.,Musculoskeletal: Complains of generalized body aches.,Psychiatric: No anxiety or depression.,Neurologic: Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION: ,She was not in any distress. She appears her stated age. Temperature 97.9. Pulse 84. Blood pressure was 110/60. Weighs 162 pounds. Height of 61 inches. Lungs - Normal effort. Clear. No wheezing. Heart - Rate and rhythm regular. No S3, no S4. Abdomen - Soft. Bowel sounds are present. No palpable hepatosplenomegaly. Extremities - Without any edema, pallor, or cyanosis. Neurological: Alert and oriented x 3. No focal deficit. Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla. Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1. I had a long discussion with family regarding the treatment of ITP. In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2. An ultrasound of the abdomen will be performed tomorrow.,3. I have given her a requisition to obtain some blood work tomorrow.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3225
}
|
DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2. Negative EKG criteria for ischemia.,3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management.cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3226
}
|
REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1. Amiodarone 200 mg once a day.,2. Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES: ,CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS: ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3227
}
|
CHIEF COMPLAINT:,1. Extensive stage small cell lung cancer.,2. Chemotherapy with carboplatin and etoposide.,3. Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with carboplatin and etoposide. She completed her fifth cycle on 08/12/10. She has had ongoing back pain and was sent for a CT scan of the thorax. She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,The patient continues to have back pain some time she also take two pain pill. She received platelet transfusion the other day and reported mild fever. She denies any chills, night sweats, chest pain, or shortness of breath. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:hematology - oncology, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3228
}
|
PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Duodenal polyp.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described. The patient was brought back into the Endoscopy Suite. The aforementioned anesthesia was given. Once the patient was properly anesthetized, bite block was placed in the patient's mouth. Then, the patient was given the aforementioned anesthesia. Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach. The air was insufflated down. The scope was passed down to the level of the antrum where there was some evidence of gastritis seen. The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen. The scope was pulled back into the stomach in order to flex upon itself and straightened out. Biopsies were taken for CLO and histology of the antrum. The scope was pulled back. The junction was visualized. No other masses or lesions were seen. The scope was removed. The patient tolerated the procedure well. We will recommend the patient be on some type of a H2 blocker. Further recommendations to follow.surgery, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3229
}
|
MEDICAL PROBLEM LIST:,1. Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2. Dementia and depression.,3. Hypertension.,4. History of atrial fibrillation. The patient has been in sinus rhythm as of late. The patient is not anticoagulated due to fall risk.,5. Glaucoma.,6. Degenerative arthritis of her spine.,7. GERD.,8. Hypothyroidism.,9. Chronic rhinitis (the patient declines nasal steroids).,10. Urinary urge incontinence.,11. Chronic constipation.,12. Diabetes type II, 2006.,13. Painful bunions on feet bilaterally.,CURRENT MEDICINES: , Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs.,ALLERGIES: , NO KNOWN DRUG ALLERGIES. ACE INHIBITOR MAY HAVE CAUSED A COUGH.,CODE STATUS:, Do not resuscitate, healthcare proxy, palliative care orders in place.,DIET:, No added salt, no concentrated sweets, thin liquids.,RESTRAINTS:, None. The patient has declined use of chair check and bed check.,INTERVAL HISTORY: , Overall, the patient has been doing reasonably well. She is being treated for some hemorrhoids, which are not painful for her. There has been a note that she is constipated.,Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. I see a couple in the 150s. However, I also see one that is in the one teens and a couple in the 120s range.,She is not bothered by cough or rib pain. These are complaints, which I often hear about.,Today, I reviewed Dr. Hudyncia's note from psychiatry. Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year.,She is not having problems with breathing. No neurologic complaints or troubles. Pain is generally well managed just with Tylenol.,PHYSICAL EXAMINATION: , Vitals: As in chart. The patient is pleasant and cooperative. She is in no apparent distress. Her lungs are clear to auscultation and percussion. Heart sounds regular to me. Abdomen: Soft. Extremities without any edema. At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.,ASSESSMENT AND PLAN:,1. Hypertension, good control, continue current.,2. Depression, well treated on Cymbalta. Continue.,3. Other issues seem to be doing pretty well. These include blood pressure, which is well controlled. We will continue the medicines. She is clinically euthyroid. We check that occasionally. Continue Tylenol.,4. For the bowels, I will increase the intensity of regimen there. I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink. I will try her on annulose and see how she does with that.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3230
}
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SUBJECTIVE:, The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120 to 140. The patient is lying down. She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:, History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1. Cardizem, which is changed to 60 mg p.o. t.i.d.,2. Digoxin 0.25 mg daily.,3. Coumadin, adjusted dose.,4. Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 122 and blood pressure 102/68.,LUNGS: Air entry decreased.,HEART: PMI is displaced. S1 and S2 are irregular.,ABDOMEN: Soft and nontender.,IMPRESSION:,1. Pulmonary disorder with lung mass.,2. Pleural effusion.,3. Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1. From cardiac standpoint, follow with pulmonary treatment.,2. The patient has an INR of 2.09. She is on anticoagulation. Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.soap / chart / progress notes, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,
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"dataset_name": "medical-transcription-4",
"id": 3231
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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.cardiovascular / pulmonary, 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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{
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PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY: ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling. The patient was started on alpha-blockers with some help, but had nocturia q.1h. The patient was given anticholinergics with minimal to no help. The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate. At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream. Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed. The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder. The patient was told that he may need anticholinergics. There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was given preoperative antibiotics. The patient was prepped and draped in the usual sterile fashion. A #23-French scope was inserted inside the urethra into the bladder under direct vision. Bilateral pyelograms were normal. The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder. There was enlargement of the lateral lobes of the prostate. The old TUR scar was visualized right at the bladder neck. Using diode side-firing fiber, the lateral lobes were taken down. The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure. Pictures were taken and were shown to the family. At the end of the procedure, there was good hemostasis. A total of about 15 to 20 minutes of lasering time was used. A #22 3-way catheter was placed. At the end of the procedure, the patient was brought to recovery in stable condition. Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.urology, laser vaporization of the prostate, cystopyelogram, benign prostatic hypertroph, benign prostatic hypertrophy, alpha blockers, laser vaporization, anticholinergics, laser, vaporization, prostate, bladder
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{
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PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE: ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. His condition is felt to be critical. In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. Subsequently a 1 cm incision was made over Kocher's point. Hemostasis was obtained. Then a twist drill was made over this area. Bones strips were irrigated away. The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed. This was then passed into the left lateral ventricle on the first pass. Excellent aggressive very bloody CSF under pressure was noted. This stopped, slowed, and some clots were noted. This was irrigated and then CSF continued. Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well. The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.surgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular
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{
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FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax. A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back. The sample will then be sent for testing. The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information. A booklet containing the description of the procedure and other information was provided.cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: 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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{
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PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1. Sixty-percent rotator cuff tear, joint side.,2. Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1. Arthroscopic subacromial decompression.,2. Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff. The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon. This was confirmed later when the bursal side was opened up. Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion. He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:, He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope. With the scope in the posterior portal, the above findings were noted, and an anterior portal was established. A curved shaver was placed for debridement of the tear. I established this was about a 60-70% tear with a probable complete area of tear which was very small. There were no problems at the biceps or the rest of the joint. The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur. I did not debride the acromioclavicular joint. The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid. The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed. The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur. Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair. The shoulder was carried through a range of motion. I could see no evidence of impingement. Copious irrigation was carried out. The deltoid deep fascia was anatomically closed, as was the superficial fascia. The subcutaneous tissue and skin were closed in layers. A sterile dressing was applied. The patient appeared to tolerate the procedure well.surgery, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff,
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{
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PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A. DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C. MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume? What drink do you prefer?,What kinds of recreational drugs have you tried? Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live? ,If you are in a relationship:,- length of the relationship: ,- name of spouse/partner: ,- age and health of spouse/partner: ,- children: ,E. POST-SURGICAL PLANS,With whom will you stay after discharge? ,What is your current occupation: ,Do you have the support of your employer?nan
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PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:, Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED: ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS: ,20 mL.,TUBES/DRAINS: ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: ,The patient is a 17-month-old boy with hypospadias abnormality. The plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. IV antibiotics were given. He was then placed in the supine position. The foreskin was retracted and cleansed. He was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed on the glans. The urethra was calibrated with the lacrimal duct probes to an 8-French. We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff. We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis. The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap. Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection. He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck. We repeated the artificial erection and the penis was straight. We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them. Using the curved iris scissors, we then also further mobilized the glanular wings. The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate. The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter. We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl. We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well. 5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans. Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans. Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff. On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place. IV Toradol was given at the procedure. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.surgery, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,
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A fluorescein angiogram was ordered at today's visit to rule out macular edema. We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress. A copy of the angiogram is enclosed for your records.soap / chart / progress notes, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, ophthalmology, lensesNOTE,: 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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{
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"dataset_name": "medical-transcription-4",
"id": 3239
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CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, , Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30): Within normal limits.,CXR (12/8): Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:, The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.nan
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PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:, The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established. The right ear was draped in normal sterile fashion. Cerumen was removed from the external canal. The extruding Santa Barbara T-tube was identified and atraumatically removed. A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.ent - otolaryngology, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic
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SUBJECTIVE:, This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back home each day which takes 20 minutes each way. She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:, Weight is 238.3 pounds. Weight from last week’s visit was 238.9 pounds. Prepregnancy weight is reported at 235 pounds. Height is 62-3/4 inches. Prepregnancy BMI is approximately 42-1/2. Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time. Blood sugar records for the last week reveal the following: Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116. Overall average is 140. A diet history was obtained. Expected date of confinement is May 1, 2005. Instructed the patient on dietary guidelines for gestational diabetes. A 2300 meal plan was provided and reviewed. The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:, Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day. Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day. Her diet history reveals that she is eating three meals a day and three snacks. The snacks were just added last week following presence of ketones in her urine. We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most. We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget. We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy. We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars. While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day. Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis. At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:, Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate. Breakfast: Three carbohydrate servings. Morning snack: One carbohydrate serving. Lunch: Four carbohydrate servings. Afternoon snack: One carbohydrate serving. Supper: Four carbohydrate servings. Bedtime snack: One carbohydrate serving. Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack. Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy. Recommend patient include a fruit or a vegetable with most of her meals. Also recommend including solid protein with each meal as well as with the bedtime snack. Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment: Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units. Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial. Provided my name and number should there be additional dietary questions.consult - history and phy., diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3242
}
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GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.,NECK: ,Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.,RESPIRATORY: , Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.,CARDIOVASCULAR:, Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.,GASTROINTESTINAL: ,No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline. Full range of motion with flexion, extension and sidebending.,SKIN:, Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.,LYMPH:, Cervical lymph nodes. No lymphadenopathy.,NEUROLOGICAL: ,Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation.office notes, respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3243
}
|
CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed. Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3244
}
|
DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:, 0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.,Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs: Clear.,Cardiac: Rhythm regular.,Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.,Lower Extremities: Without edema.,Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.hematology - oncology, radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3245
}
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CHIEF COMPLAINT:, Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizzy. She complained of a headache. She was able to walk. She continued to participate in her flag practice. She got dizzier. She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:, DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home. There is no smoking at home. There is second-hand smoke exposure.,FAMILY HISTORY: ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:, She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS: ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL: She is supine awake, alert, cooperative, and active child.,HEENT: Head atraumatic, normocephalic. Pupils equal, round, reactive to light. Extraocular motions intact and conjugate. Clear TMs, nose and oropharynx. Moist oral mucosa without noted lesions.,NECK: Supple, full painless nontender range motion.,CHEST: Clear to auscultation, equal, stable to palpation.,HEART: Regular without rubs or murmurs.,ABDOMEN: No abdominal bruits are heard.,EXTREMITIES: Equal femoral pulses are appreciated. Equal radial and dorsalis pedis pulses are appreciated. He moves all extremities without difficulty. Nontender. No deformity. No swelling.,SKIN: There was no significant bruising, lesions or rash about her abdomen. No significant bruising, lesions or rash.,NEUROLOGIC: Symmetric face and extremity motion. Ambulates without difficulty. She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:, The differential entertained includes head injury, anxiety, and hypertensive emergency. She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s. Her laboratory data shows a mildly elevated creatinine of 1.3. Urine is within normal. Urinalysis showing no signs of infection. Head CT read by staff has no significant intracranial pathology. No mass shift, bleed or fracture per Dr. X. A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90. No significant ST-T wave changes. No significant change from previous 09/2007 EKG. Her headache has resolved. She is feeling better. I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home. Follow up with her regular doctor. Blood pressures have normalized for her. She should return to emergency department on concern. They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3246
}
|
PREOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,PROCEDURES:,1. Cystoscopy.,2. Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer. His history dates back to 2003 when he had a non-muscle invasive bladder cancer. He had multiple cystoscopies and followups since that time with no evidence of recurrence. However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ. Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities. I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites. We elected to allow his bladder to recover before starting the BCG. We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter. I repeated a cystoscopy in the office with findings of a high bladder neck and BPH. After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms. There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion. A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described. We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds. Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck. The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock. Hemostasis was achieved, and then a similar procedure performed in the right side. We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis. Chips were removed with Ellik evacuator. There was no bleeding at the conclusion of the procedure, and the resectoscope was removed. A #24 French three-way Foley catheter was placed with efflux of clear irrigant. The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.urology, urinary bladder, benign prostatic hypertrophy, transurethral resection of the prostate, turp, acmi panendoscope, van buren sounds, transitional cell carcinoma, foley catheter, bladder neck, bladder, carcinoma, cystoscopy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3247
}
|
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.nephrology, 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": 3248
}
|
EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium. There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology. There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid. Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance. There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant. There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis. The small and large bowels are otherwise unremarkable. The stomach is grossly unremarkable. There is no abdominal or retroperitoneal adenopathy. There are no adrenal masses. The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance. The spleen contains several small calcified granulomas, but no evidence of masses. It is normal in size. The lung bases are clear bilaterally. The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1. Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2. Multiple uterine fibroids.,3. Prominent endometrium.,4. Followup pelvic ultrasound is recommended.gastroenterology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3249
}
|
HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED: ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver. No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION: ,1. Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2. Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3. Hypercholesterolemia.,4. History of anxiety.,5. History of coronary artery disease.,6. Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X. Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation. I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3250
}
|
HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. His viral load in July of 2007 was 254,000 and CD4 count was 7. He was recently admitted for debility and possible pneumonia. He was started on antiretroviral therapy, as well as Cipro and Flagyl and was also found to have pleural effusion on the right. His history is also significant for pancreatitis and transient renal failure during last hospitalization. He became frustrated since he was not getting better and discontinued all antibiotics. When taken home yesterday, he had symptoms consistent with a partial bowel obstruction. He was vomiting and had no bowel movements for a few days. Last night, was able to have a bowel movement and has not vomited since then. He was able to take small amounts of food. He now has persistent cough productive of clear sputum and some shortness of breath. He also complains of pain at his KS lesions on the right leg and left thigh, especially when touched, although that pain is incidental and not present when he is simply lying down. He has overall weakness.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: , Acetaminophen 650 mg q.6h. p.r.n. fever, which he has not been using, Motrin 400 mg q.6h. p.r.n. pain, which has not helped. His pain and dexamethasone with guaifenesin 5-10 mL q.4h. p.r.n. cough.,ALLERGIES:, He has no known allergies.,SOCIAL HISTORY: , The patient is now staying with his mother. He is the youngest of six children. Code Status: DNR. His brother is the health care proxy.,PHYSICAL EXAMINATION:, Blood pressure 140/80, pulse 120, and respirations 28. Temperature 103.9. General Appearance: Ill-looking young man, diaphoretic. PERRLA, 3 mm. Oral mucosa moist without lesions. Lungs: Diminished breath sounds in the right middle lower lobe. Heart: RRR without murmurs. Abdomen: Distended with soft and nontender. Diminished bowel sounds. Extremities: Without cyanosis or edema. There is a large Kaposi's sarcoma on the right medial leg and left medial proximal thigh, which is somewhat tender. Neurological Exam: Cranial nerves II through XII are grossly intact. There is normal tone. Power is 4/5. DTRs nonreactive. Normal fine touch. Mental Status: The patient is somnolent, but arousable. Withdrawn affect. Normal speech and though process.,ASSESSMENT AND PLAN:,1. AIDS complicated with multiple opportunistic infections with poor performance status, which suggested a limited prognosis of less than six months. He will benefit from home hospice care and he declined any further antibiotic or antiretroviral treatments.,2. Pain, which is somatic nociceptive from KS lesions. The patient has not tolerated morphine in the past. We will start oxycodone 5 mg q.2h. as needed.,3. Cough. We will use oxycodone with the same indication as well.,4. Fever. We encouraged him to use Tylenol as needed.,5. Insomnia. We will use lorazepam 0.25-0.5 mg at bedtime as needed.,6. Psychosocial. We discussed his coping with the diagnosis. He is fully aware of his limited prognosis. Supportive counseling was provided to his mother.,Length of the encounter was one hour; more than half spent on exchange of information.,hospice - palliative care, hospice, aids, cd4 count, code status, dnr, kaposi's sarcoma, length of the encounter, cryptococcal infection, exchange of information, health care proxy, home hospice, home hospice care, hospice care, hospitalization, viral load, bowel, infection
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3251
}
|
The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.office notes, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: 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": 3252
}
|
HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night. He denies any pain, nausea, vomiting or diarrhea. In the ER, a Foley catheter was placed and was irrigated with saline. White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9. Urine culture is pending. Chest x-ray is pending. His UA did show lots of red cells. The patient currently is comfortable. CBI is running. His urine is clear.,PAST MEDICAL HISTORY:,1. Hypertension.,2. High cholesterol.,3. Bladder cancer.,4. Bilateral total knee replacements.,5. Cataracts.,6. Enlarged prostate.,ALLERGIES:, SULFA.,MEDICATIONS AT HOME:,1. Atenolol.,2. Cardura.,3. Zegerid.,4. Flomax.,5. Levaquin.,6. Proscar.,7. Vicodin.,8. Morphine.,9. Phenergan.,10. Ativan.,11. Zocor.,12. Prinivil.,13. Hydrochlorothiazide.,14. Folic acid.,15. Digoxin.,16. Vitamin B12.,17. Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter. He does not smoke, occasionally drinks alcohol. He is independent with his activities of daily living.,REVIEW OF SYSTEMS:, Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL: An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS: BP of 162/60 and pulse oximetry of 98% on room air.,HEENT: Pink conjunctivae. Anicteric sclerae. Oral mucosa is moist.,NECK: Supple.,CHEST: Clear to auscultation.,HEART: Regular S1 and S2.,ABDOMEN: Soft and nontender to palpation.,EXTREMITIES: Without edema.,He has a Foley catheter in place. His urine is clear.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Hematuria.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3253
}
|
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.orthopedic, 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": 3254
}
|
CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly "normal.",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3255
}
|
PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:, The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes. He had required ventilator assistance and was transported to the ICU setting. Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained. The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube. The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker. The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution. The patient was prepped and draped in usual fashion. The surgeons were gowned and gloved. A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage. Blunt dissection was then carried down until the fascia overlying the strap muscles were identified. At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery. Once the strap muscles have been identified, palpation was performed to identify any arterial aberration. A high-riding innominate was not identified. At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized. Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery. Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion. This cleared a significant portion of the trachea. The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery. Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea. The second tracheal ring was identified. The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based. At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff. The airway was entered and inferior to the base, window was created. The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified. At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen. The balloon was inflated and the ventilator was attached. He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist. Now, all surgical retractors were removed. The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture. The tube was further secured around the patient's neck with IV tubing. Finally, a drain sponge was placed. At this point, procedure was felt to be complete. The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.ent - otolaryngology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3256
}
|
CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and "complete resection" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.neurology, sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: 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": 3257
}
|
PREOPERATIVE DIAGNOSIS:, Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS: ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: ,The patient was prepped and draped in the usual manner for a local eye procedure. Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done. Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus. A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed. The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron. The placement was confirmed with indirect ophthalmoscopy. Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut. The intraocular pressure was found to be within normal limits. An eye patch was applied and the patient was sent to the Recovery Room in good condition. A lateral canthotomy had been done.ophthalmology, canthotomy, ophthalmoscopy, radioactive plaque, scleral surface, macular edema, lateral canthotomy, macular
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3258
}
|
PREOPERATIVE DIAGNOSIS: ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:, General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE: ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities. The right upper extremity was exsanguinated, and the tourniquet inflated. A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament. This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon. The wound was injected, and a dry, sterile dressing was applied. An identical procedure was done to the opposite side. The patient left the operating room in satisfactory condition.orthopedic, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3259
}
|
CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3260
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HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.,EYES: Conjunctivae are now pink.,ENT: Oropharynx is clear.,CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.,LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN: Soft and nontender with no organomegaly appreciated.,EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.,NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:, Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.emergency room reports, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3261
}
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PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1. Right temporal lobe intracerebral hemorrhage.,2. Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1. Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2. Biopsy of dura.,3. Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:, Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently. This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today. She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe. There is significant mass effect. There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages. However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team. Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed. The patient was positioned supine with a three-point Mayfield head pin holder. Her scalp was prepped and draped in a sterile manner. Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly. The scalp was resected anteriorly. The subdural scar was noted, and hemostasis was achieved using Bovie cautery. The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety. The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected. It was quite full. The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur. The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax. The dura pack-up stitches were noted around the periphery from the previous craniotomy. This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure. Using a #15 blade, a new durotomy was then made. Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope. The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface. Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered. The parenchyma of the brain did not appear normal. It was quite vascular. Furthermore, there was a hematoma mixed in with the brain itself. Thus a core biopsy was then performed in the temporal tip. The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology. Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished. No attempt was made to enter into the sylvian fissure. Once hemostasis was meticulously achieved, the brain was inspected. It still was quite swollen, known that there was still hematoma in the parenchyma of the brain. However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed. DuraGen was then used for duraplasty because of the resected dura. The bone flap was then repositioned using Lorenz plating system. Then a medium Hemovac drain was placed in subdural space. Temporalis muscle was approximated using 2-0 Vicryl. The galea was then reapproximated using inverted 2-0 Vicryl. The scalp was then reapproximated using staples. The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly. The pupils are 3 mm bilaterally reactive to light. I accompanied her and transported her to the ICU where I signed out to the ICU attending.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3262
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PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:, General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark. This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion. Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence. She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION: ,The patient came to the operating room, had an uneventful induction of general anesthesia. We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today. Preparation and draping was __________ ensued with a chlorhexidine based prep solution. The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm. This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin. Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil. The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure. The patient tolerated the procedure well. This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma. Blood loss was less than 5 mL and there were no complications.surgery, trochanter, granuloma, pyogenic granuloma, vascular malformation, pyogenic, vascular, malformation, thigh,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3263
}
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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.,orthopedic, 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": 3264
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PREOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIONS PERFORMED:, Endoscopic carpal tunnel release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.orthopedic, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3265
}
|
1. Odynophagia.,2. Dysphagia.,3. Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Hiatal hernia.,PROCEDURE PERFORMED: EGD with photos and biopsies.,GROSS FINDINGS: This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently. At this time, an EGD was performed to rule out stricture. At the time of EGD, there was noted some antral gastritis and hiatal hernia. There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE: The patient was taken to the Endoscopy Suite in the lateral decubitus position. She was given sedation by the Department Of Anesthesia. Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx. With air insufflation entered through the proximal esophagus to the GE junction. The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices. There was a hiatal hernia present. The scope was passed through the hiatal hernia into the body of the stomach. In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions. Multiple biopsies were obtained. The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits. The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction. As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn. The patient tolerated the procedure well and sent to recovery room in satisfactory condition.gastroenterology, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3266
}
|
PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease. It was carried sharply down to the transverse wrist crease. The transverse carpal ligament was identified and released under direct vision. Proximal to the transverse wrist crease it was released subcutaneously. During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch. The nerve appeared to be mildly constricted. Closure was routine with running 5-0 nylon. A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.surgery, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3267
}
|
IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3268
}
|
CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.radiology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3269
}
|
SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requests information on diabetic exchanges. She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs: The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004. I praised her weight loss and her regular exercising. I looked at her food journal. I praised her record keeping. I gave her a list of the diabetic exchanges and explained them. I also gave her a food dairy sheet so that she could record exchanges. I encouraged her to continue.,ASSESSMENT:, The patient seems happy with her progress and she seems to be doing well. She needs to continue.,PLAN:, Followup is on a p.r.n. basis. She is always welcome to call or return.diets and nutritions, overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3270
}
|
CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: , This is an 86-year-old female who is a patient of Dr. X, who was transferred from ABCD Home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday. During evaluation in the emergency room, the patient was found to have a high amylase as well as lipase count and she is being admitted for management of acute pancreatitis.,PAST MEDICAL HISTORY:, Significant for dementia of Alzheimer type, anxiety, osteoarthritis, and hypertension.,ALLERGIES: , THE PATIENT IS ALLERGIC TO POLLENS.,MEDICATIONS: , Include alprazolam 0.5 mg b.i.d. p.r.n., mirtazapine 30 mg p.o. daily, Aricept 10 mg p.o. nightly, Namenda 10 mg p.o. b.i.d., Benicar 40 mg p.o. daily, and Claritin 10 mg daily p.r.n.,FAMILY HISTORY: , Not available.,PERSONAL HISTORY: ,Not available.,SOCIAL HISTORY: ,Not available. The patient lives at a skilled nursing facility.,REVIEW OF SYSTEMS: ,She has moderate-to-severe dementia and is unable to give any information about history or review of systems.,PHYSICAL EXAMINATION:,GENERAL: She is awake and alert, able to follow few simple commands, resting comfortably, does not appear to be in any acute distress.,VITAL SIGNS: Temperature of 99.5, pulse 82, respirations 18, blood pressure of 150/68, and pulse ox is 90% on room air.,HEENT: Atraumatic. Pupils are equal and reactive to light. Sclerae and conjunctivae are normal. Throat without any pharyngeal inflammation or exudate. Oral mucosa is normal.,NECK: No jugular venous distention. Carotids are felt normally. No bruit appreciated. Thyroid gland is not palpable. There are no palpable lymph nodes in the neck or the supraclavicular region.,HEART: S1 and S2 are heard normally. No murmur appreciated.,LUNGS: Clear to auscultation.,ABDOMEN: Soft, diffusely tender. No rebound or rigidity. Bowel sounds are heard. Most of the tenderness is located in the epigastric region.,EXTREMITIES: Without any pedal edema, normal dorsalis pedis pulsations bilaterally.,BREASTS: Normal.,BACK: The patient does not have any decubitus or skin changes on her back.,LABS DONE AT THE TIME OF ADMISSION: , WBC of 24.3, hemoglobin and hematocrit 15.3 and 46.5, MCV 89.3, and platelet count of 236,000. PT 10.9, INR 1.1, PTT of 22. Urinalysis with positive nitrite, 5 to 10 wbc's, and 2+ bacteria. Sodium 134, potassium 3.6, chloride 97, bicarbonate 27, calcium 8.8, BUN 25, creatinine 0.9, albumin of 3.4, alkaline phosphatase 109, ALT 121, AST 166, amylase 1797, and lipase over 3000. X-ray of abdomen shows essentially normal abdomen with possible splenic granulomas and degenerative spine changes. CT of the abdomen revealed acute pancreatitis, cardiomegaly, and right lung base atelectasis. Ultrasound of the abdomen revealed echogenic liver with fatty infiltration. Repeat CBC from today showed white count to be 21.6, hemoglobin and hematocrit 13.9 and 41.1, platelet count is normal, 89% segments and 2% bands. Sodium 132, potassium 4.0, chloride 98, bicarbonate 22, glucose 184, ALT 314, AST 382, amylase 918, and lipase 1331. The cultures are pending at this time. EKG shows sinus rhythm, rate about 90 per minute, multiple ventricular premature complexes are noted. Troponin 0.004 and myoglobin is 39.6.,ASSESSMENT:,1. Acute pancreatitis.,2. Leukocytosis.,3. Urinary tract infection.,4. Hyponatremia.,5. Dementia.,6. Anxiety.,7. History of hypertension.,8. Abnormal electrocardiogram.,9. Osteoarthrosis.,PLAN:, Admit the patient to medical floor, NPO, IV antibiotics, IV fluids, hold p.o. medications, GI consult, pain control, Zofran IV p.r.n., bedrest, DVT prophylaxis, check blood and urine cultures. I have left a message for the patient's son to call me back.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3271
}
|
PROBLEM: ,Rectal bleeding, positive celiac sprue panel.,HISTORY: ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits. She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody. She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved. She actually has none of these symptoms since starting her gluten-free diet. She has noted intermittent rectal bleeding with constipation, on the toilet tissue. She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco. No ethanol.,SOCIAL HISTORY: , She lives by herself. She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well. She has two sisters and one brother. One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS: ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet. She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination. Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION: , GENERAL: She is a well-developed pleasant 19 female. She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds. She has anicteric sclerae. Pink conjunctivae. PERRLA. ENT: MMM. NECK: Supple. LUNGS: Clear to auscultation.consult - history and phy., bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3272
}
|
CHIEF REASON FOR CONSULTATION:, Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:, This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1. Astelin nasal spray.,2. Evista 60 mg daily.,3. Lopressor 25 mg daily.,4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:, The patient underwent right foot surgery and C-section.,FAMILY HISTORY:, The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks. ,ALLERGIES:, THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:, Otherwise negative. ,PHYSICAL EXAMINATION: , ,GENERAL: Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.,NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.,CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. ,CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.,ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.,EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO: Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3273
}
|
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.cardiovascular / pulmonary, 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": 3274
}
|
SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet.consult - history and phy., vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3275
}
|
PROBLEM LIST:,1. Generalized osteoarthritis and osteoporosis with very limited mobility.,2. Adult failure to thrive with history of multiple falls, none recent.,3. Degenerative arthritis of the knees with chronic bilateral knee pain.,4. Chronic depression.,5. Hypertension.,6. Hyperthyroidism.,7. Aortic stenosis with history of CHF and bilateral pleural effusions.,8. Right breast mass, slowly enlarging. Patient refusing workup.,9. Status post ORIF of the right wrist, now healed.,10. Anemia of chronic disease.,11. Hypoalbuminemia.,12. Chronic renal insufficiency.,CURRENT MEDICATIONS:, Acetaminophen 325 mg 2 tablets twice daily, Coreg 6.25 mg twice daily, Docusate sodium 100 mg 1 cap twice daily, ibuprofen 600 mg twice daily with food, Lidoderm patch 5% to apply 1 patch to both knees every morning and off in the evening, one vitamin daily, ferrous sulfate 325 mg daily, furosemide 20 mg q.a.m., Tapazole 5 mg daily, potassium chloride 10 mEq daily, Zoloft 50 mg daily, Ensure t.i.d., and p.r.n. medications.,ALLERGIES:, NKDA.,CODE STATUS:, DNR, healthcare proxy, durable power of attorney.,DIET:, Regular with regular consistency with thin liquids and ground meat.,RESTRAINTS: , None. She does have a palm protector in her right hand.,INTERVAL HISTORY:, No significant change over the past month has occurred. The patient mainly complains about pain in her back. On a scale from 1 to 10, it is 8 to 10, worse at night before she goes to bed. She is requesting something more for the pain. Other than that, she complains about her generalized pain. There has been no significant change in her weight. No fever or chills. No complaint of headaches or visual changes, chest pain, shortness of breath, dyspnea on exertion, orthopnea, or PND. No hemoptysis or night sweats. No change in her bowels, abdominal pain, bright red rectal bleeding, or melena. No nausea or vomiting. Her appetite is fair. She is a picky eater but definitely likes her candy. There has been no change in her depression. It seems to be stable on the Zoloft 50 mg daily, which she has been on since October 17, 2006. She denies feeling depressed to me but complains of being bored, stating she just sits and watches TV or sometimes may go to activities but not very seldom due to her back pain. No history of seizures. She denies any tremors. She is hyperthyroid and is on replacement.,PHYSICAL EXAMINATION: , An elderly female, sitting in a wheelchair, in no acute distress, very kyphotic. She is very pleasant and alert. Vital signs per chart. Skin is normal in texture and turgor for her age. She does have dry lips, which she picks at and was picking at her lips while I was talking with her. HEENT: Normocephalic, atraumatic. She has nevi above her left eye, which she states she has had since birth and has not changed. Pupils are equal, round and reactive to light and accommodation. No exophthalmos or lid lag. Anicteric sclerae. Conjunctivae pink, nasal passages clear. She is edentulous but does have her upper dentures in. No mucosal ulcerations. External ears normal. Neck is supple. No increased JVD, cervical or supraclavicular adenopathy. No thyromegaly or masses. Trachea is midline. Her chest is very kyphotic, clear to A&P. Heart: Regular rate and rhythm with a 2-3/6 systolic murmur heard best at the left sternal border. Abdomen: Soft. Good bowel sounds. Nontender. Unable to appreciate any organomegaly or masses as she is sitting in a wheelchair. Extremities are without edema, cyanosis, clubbing, or tremor. She does have Lidoderm patches over both of her knees and is wearing a brace in her right hand.,LABORATORY TESTS: , Albumin was 3.2 on 12/06/06. Dietary is aware. Electrolytes done 11/28/06, her sodium was 144, potassium 4.4, chloride 109, bicarbonate 26, anion gap 9, BUN 28, creatinine 1.2, GFR 44. Digoxin was done and was less than 0.9, but she is not on digoxin. CBC showed a white count of 7400, hemoglobin 11.1, hematocrit 35.9, MCV of 95.2, and platelet count of 252,000. Her TSH was 1.52. No changes were made in her Tapazole.,ASSESSMENT AND PLAN:, We will continue present therapy except we will add Tylenol No. 3 to take 1 tablet before bed as needed for her back pain. If she does develop drowsiness from this, then the CNS side effects will help her sleep. During the day, her daughter likes the patient to remain alert and will use the ibuprofen at that time as long as she does not develop any GI symptoms. We will make sure that she is taking the ibuprofen with food. No further laboratory tests will be done at this time.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3276
}
|
2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. Pulmonary outflow is normal at the valve. Pulmonary venous return is to the left atrium. The interatrial septum is intact. Mitral inflow and ascending aorta flow are normal. The aortic valve is trileaflet. The coronary arteries appear to be normal in their origins. The aortic arch is left-sided and patent with normal descending aorta pulsatility.radiology, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: 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": 3277
}
|
PROCEDURE:, Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS:, See nurse's records.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE:, INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition.pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3278
}
|
PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.surgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3279
}
|
GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers. No tattoos.,NECK:, Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:, Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.,LUNGS:, Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.,MUSCULOSKELETAL:, Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.,GENITOURINARY: ,Deferred.,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3280
}
|
CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3281
}
|
PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.,IMPRESSION: ,Normally functioning pacemaker ICD post implant day number 1.surgery, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3282
}
|
SUBJECTIVE:, The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120 to 140. The patient is lying down. She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:, History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1. Cardizem, which is changed to 60 mg p.o. t.i.d.,2. Digoxin 0.25 mg daily.,3. Coumadin, adjusted dose.,4. Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 122 and blood pressure 102/68.,LUNGS: Air entry decreased.,HEART: PMI is displaced. S1 and S2 are irregular.,ABDOMEN: Soft and nontender.,IMPRESSION:,1. Pulmonary disorder with lung mass.,2. Pleural effusion.,3. Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1. From cardiac standpoint, follow with pulmonary treatment.,2. The patient has an INR of 2.09. She is on anticoagulation. Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3283
}
|
HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. The patient reports she has been having daily headaches since 02/25/2008. She has been getting pulsations in the head with heartbeat sounds. Headaches are now averaging about three times per week. They are generally on the very top of the head according to the patient. Interestingly, she denies any previous significant history of headaches prior to this. There has been no nausea associated with the headaches. The patient does note that when she speaks on the phone, the left ear has "weird sounds." She feels a general fullness in the left ear. She does note pulsation sounds within that left ear only. This began on February 17th according to the patient. The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family. The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks. Interestingly, there has been no significant drop or change in her hearing. She does report she has had dizzy episodes in the past with nausea, being off balance at times. It is not associated with the pulsations in the ear. She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear. She is denying any vision changes. The headaches are listed as moderate to severe in intensity on average about three to four times per week. She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC: Negative.,CARDIOVASCULAR: Hypercholesterolemia.,PULMONARY: Negative.,GASTROINTESTINAL: Pertinent for nausea.,GENITOURINARY: The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC: History of dizziness and the headaches as listed above.,VISUAL: Negative.,DERMATOLOGIC: History of itching. She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE: Negative.,MUSCULOSKELETAL: Negative.,CONSTITUTIONAL: She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:, She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:, Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married. She works at Eye Center as a receptionist. She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS: Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL: The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: There is an old mastoidectomy scar, left ear. The ear canals are clean and dry. Drums intact and mobile. Weber exam is midline. Grossly hearing is intact. Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL: Reveals clear drainage. Deviated nasal septum to the left, listed as mild to moderate. Ostiomeatal complexes are patent and turbinates are healthy. There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy. See fiberoptic nasopharyngoscopy separate exam.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,IMPRESSION: ,1. Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology. Consider, also normal pressure hydrocephalus.,2. Recurrent headaches.,3. Deviated nasal septum.,4. Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet. I have also ordered a carotid ultrasound study as part of the workup and evaluation. She has had a recent CAT scan of the brain though this was without contrast. It did reveal previous mastoidectomy, left temporal bone, but no other mass noted. I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related. Hearing protection devices should be used at all times as well. I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues. I am going to recheck her in three weeks. If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office. She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.nan
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3284
}
|
PREOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1. Right McBride bunionectomy.,2. Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position. The right foot was prepared and draped in usual sterile manner. Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint. Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg. At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made. The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure. The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection. Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp. At this time, attention was directed to the first inner space using sharp and blunt dissection. Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments. The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment. At this time, the lateral release was stressed and was found to be complete. The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw. The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted. At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length. The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption. At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint. At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge. The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm. The screw was placed following proper technique. The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing. A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy. The packing of the cancellous bone was held in place with bone wax. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed. At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion. The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site. At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily. The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion. The tourniquet was dropped and color and temperature of all digits returned to normal. The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided. The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,podiatry, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3285
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PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:, Left carpal tunnel release.,FINDINGS:, Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS: ,None.,FLUIDS:, 500 mL of crystalloids.,URINE OUTPUT:, No Foley catheter.,COMPLICATIONS: , None.,ANESTHESIA: , General through a laryngeal mask.,ESTIMATED BLOOD LOSS: , None.,CONDITION: , Resuscitated with stable vital signs.,INDICATION FOR THE OPERATION: , This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation. At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now. Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia. There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection. He understood this risk and agreed to have the procedure performed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table. The left upper extremity was then prepped with Betadine soap and antiseptic solution. After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg. Clamp time approximately 30 minutes. An incision was then made right in the mid palm area between the thenar and hypothenar eminence. Meticulous hemostasis of any bleeders were done. The fat was identified. The palmar aponeurosis was identified and cut and this was traced down to the wrist. There was severe compression of the median nerve. Additional removal of the aponeurosis was performed to allow for further decompression. After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches. Dressing was applied. The patient was brought to the recovery.surgery, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3286
}
|
HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals. The patient's complete medical history is unknown to me at this time. The patient was cooperative and compliant throughout this evaluation.,STUDY:, Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair. To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE: ,The patient had no difficulty with bolus control and transport. No spillage out lips. The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation. We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE: ,No aspiration or penetration occurred during this evaluation. The patient's hyolaryngeal elevation and anterior movements are within the functional limits. Epiglottic inversion is within functional limits. She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: ,The patient had no aspiration or penetration occurred during this evaluation. She does appear to have a diverticulum in the area between her right faucial pillars. Additional evaluation is needed by an ENT physician.,PLAN: ,Based on this evaluation, the following is recommended:,1. The patient's diet should consist regular consistency food with thin liquids. She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care. She is not in need of skilled speech therapy and is discharged from my services.consult - history and phy., globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3287
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|
PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF. The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed. The patient was noted at that time to have transglottic edema. Biopsies were taken. At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection. The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support. A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit. The patient was placed in a supine position. The neck was then extended. The sutures that were previously in place in the #6 Shiley with proximal extension were removed. The patient was preoxygenated to 100%. After several minutes, the patient was noted to have a pulse oximetry of 100%. The IV tubing that was supporting the patient's trache was then cut. The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire. The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned. With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea. The guidewire was then removed and the inner cannula was then placed into the tracheostomy. The patient was then reconnected to the ventilator and was noted to have normal tidal volumes. The patient had a tidal volume of 500 and was returning 500 cc to 510 cc. The patient continued to saturate well with saturations 99%. The patient appeared comfortable and her vital signs were stable. A soft trache collar was then connected to the trachesotomy. A drain sponge was then inserted underneath the new trache site. The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well. 0.25% acetic acid soaks were ordered to the drain sponge every shift.surgery, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3288
}
|
HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. His urinary function had been stable until 2 days ago. Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks). His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional. The bowel function is stable with occasional irritative hemorrhoidal symptoms. He has had no hematochezia. The PSA has been slowly rising in recent months. This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days. No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100. He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds. (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1. NyQuil.,2. Timolol eye drops.,3. Aspirin.,4. Advil.,5. Zinc.,PHYSICAL EXAMINATION,GENERAL: Pleasant, well-developed, gentleman in no acute distress. Weight is 197 pounds.,HEENT: Sclerae and conjunctivae are clear. Extraocular movement are intact. Hearing is grossly intact. The oral cavity is without thrush. There is minor pharyngitis.,LYMPH NODES: No palpable lymphadenopathy.,SKELETAL: No focal skeletal tenderness.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION: There are external hemorrhoids. The prostate fossa is flat without suspicious nodularity. There is no blood on the examining glove.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: Without focal deficit.,IMPRESSION:, Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient. He understands the probability that there may be residual cancer although the location is unknown. For now there is no good evidence that early management affects the ultimate prognosis. Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA. I also suggested that he reestablish contact with Dr. X at his convenience.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3289
}
|
CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3290
}
|
HISTORY:, The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss. The patient reports that she has been having history of recurrent sinus infection, averages about three times per year. During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well. The patient does note that she has been having hearing loss. This is particular prominent in the right ear now for the past three to four years. She does note popping after blowing the nose. Occasionally, the hearing will improve and then it plugs back up again. She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her. She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement. She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage. She feels that she is having a hard time swallowing at times as well. She has complained of a lump sensation in the throat that tends to come and go. She denies any cough, no hemoptysis, no weight change. No night sweats, fever or chills has been noted. She is having at this time no complaints of tinnitus or vertigo. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: ,ALLERGY/IMMUNOLOGIC: History of seasonal allergies. She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR: Pertinent for hypercholesterolemia.,PULMONARY: She has a history of cough, wheezing.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: She has had a history of TIAs in the past.,VISUAL: She does have history of vision change, wears glasses.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: History of joint pain and bursitis.,CONSTITUTIONAL: She has a history of chronic fatigue.,ENT: She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC: History of anxiety, depression.,HEMATOLOGIC: Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984. She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension. Brother, colon CA. Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily. She takes vitamins one a day. She is on Zocor, Desyrel, Flonase, and Xanax. She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling. She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single. She is unemployed at this time. She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL: The patient is an alert, cooperative, well-developed 51-year-old female. She has a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Right ear, the external ear is normal. The ear canal is clean and dry. The drum is intact. She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss. Left ear, the external ear is normal. The ear canal is clean and dry. The drum is intact and mobile with grossly normal hearing. The audiogram does reveal normal hearing in the left ear. She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally. Tympanograms, there was no adequate seal obtained on the right side. She has a normal type A tympanogram, left side.,NASAL: Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms. Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted. The nasopharynx does reveal moderate adenoid pad within this midline. It is nonulcerated. The larynx revealed both cords to be normal. She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION: ,1. Persistent dysphagia. I think secondary most likely to the persistent postnasal drainage.,2. Deviated nasal septum.,3. Inferior turbinate hypertrophy.,4. Chronic rhinitis.,5. Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3291
}
|
GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:nan
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3292
}
|
PAST MEDICAL HISTORY:, Significant for hypertension. The patient takes hydrochlorothiazide for this. She also suffers from high cholesterol and takes Crestor. She also has dry eyes and uses Restasis for this. She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout. She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993. She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash. The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker. She only drinks socially one to two drinks a month. She is employed as a manager at the New York department of taxation. She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure. She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes. She also complains about snoring and occasional slight asthma. She does complain about peripheral ankle swelling and heartburn. She also gives a history of hemorrhoids and bladder infections in the past. She has weight bearing joint pain as well as low back degenerating discs. She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION: ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20. Well nourished, well developed in no distress. Eye exam, pupils equal round and reactive to light. Extraocular motions intact. Neuro exam deep tendon reflexes 1+ in the lower extremities. No focal neuro deficits noted. Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit. Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished. Cardiac exam regular rate and rhythm without murmur or bruit. Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen. No palpable tenderness. No right upper quadrant tenderness. No organomegaly appreciated. No obvious hernias noted. Lower extremity exam +1 edema noted. Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities. The patient is interested in gastric bypass surgery. The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels. Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively. I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.bariatrics, weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3293
}
|
HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen. She was also noted to have periodic breathing. The patient is breast and bottle-fed and has been feeding well. There has been no diarrhea or vomiting. Voiding well. Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section. Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa. The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL: The patient is icteric, well hydrated. Does have periodic breathing. Color is pink and also icterus is noted, scleral and skin.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular with a soft 3/6 murmur. Femorals are well palpable. Cap refill is immediate,ABDOMEN: Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA: Those of a female child.,SKIN: Color icteric. Nonspecific rash on the body, which is sparse. The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES: The patient moves all extremities well. Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen. Parents were made aware of the fact that child did have a murmur. I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning. The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos. Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%. Total bilirubin was 25.4 mg, all of which was unconjugated. CRP was 0.3 mg%. Blood culture was drawn. Catheterized urine specimen was normal. Parents were kept abreast of what was going on all the time and the need for admission. Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:, Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.pediatrics - neonatal, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia,
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{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3294
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ALLOWED CONDITIONS:, Lateral epicondylitis, right elbow,EMPLOYER:, ABCD,REQUESTED ALLOWANCE:, Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars. He does state he was employed for such company for the last five years. His work includes lots of pulling, pushing, and working in weird angles. He does state on the date of injury, he was not doing anything additional.,TREATMENT HISTORY: , Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger. He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility. He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger. He was placed on light duty for the next couple of months. Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007. He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007. Thereafter, he continued to work in a light duty type of basis for the next few months.,An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome. He was able to return to work doing more of a light duty type of position.,The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008. It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition. The injured worker subsequently was placed in a no work status thereafter.,At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger. There are times when the whole hand becomes very numb. He does not use and do any type of lifting with regards to the right hand secondary to the discomfort. His pain does vary between a 4 on a scale of 1 to 10. He denies any weakness. He does not awaken at night with the symptomatology. Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms. He does state that he is right-handed.,In addition, he does note numbness and tingling as related to the left hand. He has not had any type of EMG and nerve conduction study as related to the left upper extremity.,CURRENT MEDICATIONS: , None.,ALLERGIES:, Zyrtec.,SURGERIES: , Left shoulder surgery.,SOCIAL HISTORY: , The injured worker denies tobacco or alcohol consumption.,PHYSICAL EXAMINATION:, Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds. He does not appear to be in distress at this time.,On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis. The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees. Tinel's and Phalen's tests were positive. Reverse Phalen's test was negative. There is diminished sensation in distribution of the thumb, index, middle, and ring finger. The intrinsic function did appear to be intact. The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow. The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees. Tinel's test is negative as related to the elbow and the ulnar nerve.,There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.,RECORDS REVIEW: ,1. First report of injury, difficulty as related to both hands.,2. Number of notes of Occupational Health Clinic. It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.,3. December 20, 2007, operative note of Dr. Y. At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.,4. November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.,ASSESSMENT: , Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.,Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.,It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009. Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region. It also should be noted that really there is no significant weakness as related to the function of the right upper extremity. Also noted is there is an absence of tenderness as related to the lateral epicondylar region.,QUESTION: ,Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.,ANSWER: ,Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis. This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.,QUESTION: ,Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing. Please explain.,ANSWER: ,There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing. As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.,QUESTION: ,If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement. Please also give an estimated time for maximum medical improvement.,ANSWER: ,The injured worker has indeed reached maximum medical improvement as related to the elbow. There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis. At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.,QUESTION: ,Is the claimant suffering from carpal tunnel syndrome, right?nan
|
{
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"dataset_name": "medical-transcription-4",
"id": 3295
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PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:, Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:, Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area. The patient was positioned in the modified beachchair position utilizing the Mayfield headrest. The left shoulder was propped posteriorly with a rolled towel. His head was secured to the Mayfield headrest. The left shoulder and upper extremity were then prepped and draped in the usual manner. A posterior lateral port was made for _____ the arthroscopic cannula. The scope was introduced into the glenohumeral joint. There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock. The labrum was adherent to the underlying capsule. The margin of the glenoid was frayed in this area. The biceps tendon was noted to be intact. The articular surface of the glenoid was fairly well preserved. The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head. The rotator cuff was visualized and noted to be intact. The axillary pouch was visualized and it was free of injury. There were some cartilaginous fragments within the axillary pouch. Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum. Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position. A second tack was then placed at about the 8 o'clock position. The labrum was then probed and was noted to be stable. With some general ranging of the shoulder, the tissue was pulled out from the tacks. An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position. Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area. At this point, it was deemed that an open Bankart arthroplasty was necessary. The arthroscopic instruments were removed. An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold. The skin incision was taken down through the skin. Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis. The deltopectoral fascia was identified. It was split at the deltopectoral interval and the deltoid was reflected laterally. The subdeltoid bursa was then removed with rongeurs. The conjoint tendon was identified. The deltoid and conjoint tendons were then retracted with a self-retaining retractor. The subscapularis tendon was identified. It was separated about a centimeter from its insertion, leaving the tissue to do sew later. The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially. This allowed for visualization of the capsule. The capsule was split near the humeral head insertion leaving a tag for repair. It was then split longitudinally towards the glenoid at approximately 9 o'clock position. This provided visualization of the glenohumeral joint. The friable labral and capsular tissue was identified. The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock. The sutures were passed through the labral capsular tissue and tied securely. At this point, the anterior glenoid rim had been recreated. The joint was then copiously irrigated with gentamicin solution and suctioned dry. The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture. This later was then copiously irrigated with gentamicin solution and suctioned dry. Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture. This later was then copiously irrigated as well and suctioned dry. The deltoid fascia was approximated with running #2-0 Vicryl suture. Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips. 0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia. The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied. The patient was then transferred to the recovery room in apparent satisfactory condition.orthopedic, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3296
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REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.gastroenterology, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication,
|
{
"dataset_link": "https://huggingface.co/datasets/rungalileo/medical_transcription_4",
"dataset_name": "medical-transcription-4",
"id": 3297
}
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HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2. Mild left atrial enlargement.,3. Intracardiac thrombus identified at the base of the left atrial appendage.,4. Mild mitral regurgitation with two jets.,5. Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic
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"dataset_name": "medical-transcription-4",
"id": 3298
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DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.hematology - oncology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,
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{
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"dataset_name": "medical-transcription-4",
"id": 3299
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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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