transcription stringlengths 11 18.4k | medical_specialty int64 0 39 |
|---|---|
preoperative diagnosis:, closed displaced probable pathological fracture, basicervical femoral neck, left hip.,postoperative diagnosis: , closed displaced probable pathological fracture, basicervical femoral neck, left hip.,procedures performed:,1. left hip cemented hemiarthroplasty.,2. biopsy of the tissue from the... | 27 |
chief complaint:,1. stage iiic endometrial cancer.,2. adjuvant chemotherapy with cisplatin, adriamycin, and abraxane.,history of present illness: , the patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. in march 2010, she had an abnormal endometrial ultrasound with t... | 35 |
endovascular brachytherapy (ebt),the patient is to undergo a course of angioplasty for in-stent restenosis. the radiotherapy will be planned using simulation films when the novoste system catheter markers are placed on either side of the coronary artery injury site. after this, a calculation will take place to determ... | 3 |
subjective:, this 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. it cleared for awhile. this has been an intermittent problem. n... | 5 |
chief complaint: , mental changes today.,history of present illness: , this patient is a resident from mazatlan, mexico, visiting her son here in utah, with a history of diabetes. she usually does not take her meal on time, and also not having her regular meals lately. the patient usually still takes her diabetic med... | 15 |
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 imagin... | 33 |
reason for visit: , mr. abc is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. he returns today to review his response to cpap.,history of present illness: , the patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. he was found to ... | 36 |
exam: , ct pelvis with contrast and ct abdomen with and without contrast.,indications: ,abnormal liver enzymes and diarrhea.,technique: , ct examination of the abdomen and pelvis was performed after 100 ml of intravenous contrast administration and oral contrast administration. pre-contrast images through the abdomen... | 21 |
preoperative diagnosis:,1. left chronic anterior and posterior ethmoiditis.,2. left chronic maxillary sinusitis with polyps.,3. left inferior turbinate hypertrophy.,4. right anterior and posterior chronic ethmoiditis.,5. right chronic maxillary sinusitis with polyps.,6. right chronic inferior turbinate hypertroph... | 38 |
preoperative diagnoses,1. cervical spinal stenosis, c3-c4 and c4-c5.,2. cervical spondylotic myelopathy.,postoperative diagnoses,1. cervical spinal stenosis, c3-c4 and c4-c5.,2. cervical spondylotic myelopathy.,operative procedures,1. radical anterior discectomy, c3-c4 with removal of posterior osteophytes, forami... | 23 |
title of operation:, endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,indication for surgery: , she is a 3-year-old girl who is known to have a head injury and ct in 2005 was normal, presented with headache. all endocrine labs were normal. surgery was recommended.,preop diagnosis: , cys... | 23 |
preoperative diagnosis (es):, cataract, right eye.,postoperative diagnosis (es):, cataract, right eye.,procedure:, right phacoemulsification of cataract with intraocular lens implantation.,description of the operation:, under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positio... | 26 |
cc:, orthostatic lightheadedness.,hx:, this 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. the dizziness worsened when moving into upright positions. in addition, he complained of intermittent throbbing holocranial h... | 22 |
preoperative diagnosis:,1. cholelithiasis.,2. chronic cholecystitis.,postoperative diagnosis:,1. cholelithiasis.,2. chronic cholecystitis.,name of operation: , laparoscopic cholecystectomy.,anesthesia:, general.,findings:, the gallbladder was thickened and showed evidence of chronic cholecystitis. there was a gr... | 38 |
chief complaint:, this 3-year-old female presents today for evaluation of chronic ear infections bilateral.,associated signs and symptoms for otitis media: , associated signs and symptoms include: cough, fever, irritability and speech and language delay. duration (ent): duration of symptom: 12 rounds of antibiotic... | 29 |
chief complaint: , jaw pain.,history of present illness: ,this is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. triage nurse reported that he does not believe it is his tooth because he has regular dental appointmen... | 12 |
chief complaint:, questionable foreign body, right nose. belly and back pain. ,subjective: , mr. abc is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. this does not seem to be slowing him down. they have not noticed any change in his urine or bowels... | 12 |
preoperative diagnoses:,1. prostatism.,2. bladder calculus.,operation:, holmium laser cystolithalopaxy.,postoperative diagnoses:,1. prostatism.,2. bladder calculus.,anesthesia: ,general.,indications:, this is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self... | 39 |
clinical history: ,probable right upper lobe lung adenocarcinoma.,specimen: , lung, right upper lobe resection.,gross description:, specimen is received fresh for frozen section, labeled with the patient's identification and "right upper lobe lung". it consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.c... | 19 |
problem: ,prescription evaluation for crohn's disease., ,history: , this is a 46-year-old male who is here for a refill of imuran. he is taking it at a dose of 100 mg per day. he is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. in fact,... | 5 |
without difficulty, into the upper gi tract. the anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected. all structures were visually normal in appearance. biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent... | 14 |
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, bleedi... | 5 |
preoperative diagnosis: , umbilical hernia.,postoperative diagnosis: , umbilical hernia.,procedure performed: , repair of umbilical hernia.,anesthesia: , general.,complications: , none.,estimated blood loss: , minimal.,procedure in detail: ,the patient was prepped and draped in the sterile fashion. an infraumbilical ... | 39 |
preoperative diagnosis:, recurring bladder infections with frequency and urge incontinence, not helped with detrol la.,postoperative diagnosis: , normal cystoscopy with atrophic vaginitis.,procedure performed: , flexible cystoscopy.,findings:, atrophic vaginitis.,procedure: ,the patient was brought in to the procedu... | 39 |
preoperative diagnoses:,1. enlarged fibroid uterus.,2. abnormal uterine bleeding.,postoperative diagnoses:,1. enlarged fibroid uterus.,2. abnormal uterine bleeding.,procedure performed: , total abdominal hysterectomy with a uterosacral vault suspension.,anesthesia: , general with endotracheal tube as well as spinal... | 38 |
subjective:, the patient returns to the pulmonary medicine clinic for followup evaluation of copd and emphysema. she was last seen in the clinic in march 2004. since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. she is very frustrated with her living situation and w... | 35 |
history: , the patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in september of 2005. at that time, she did not notice any specific injury. five days later, she started getting abnormal right low back pain. at this time, it ... | 30 |
s:, the patient is here today with his mom for several complaints. number one, he has been having issues with his right shoulder. approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. he has been having issues ever since. he is having difficulties raising his a... | 15 |
history of present illness: , this is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for q-fever endocarditis. he is also taking digoxin, aspirin, warfarin, and furosemide. mother reports tha... | 3 |
reason for referral: , elevated bnp.,history of present illness:, the patient is a 95-year-old caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's bnp level was high, for which card... | 3 |
discharge diagnoses:,1. end-stage renal disease, on hemodialysis.,2. history of t9 vertebral fracture.,3. diskitis.,4. thrombocytopenia.,5. congestive heart failure with ejection fraction of approximately 30%.,6. diabetes, type 2.,7. protein malnourishment.,8. history of anemia.,history and hospital course: , t... | 21 |
history: , the patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. she was undergoing a spinal epidural injection about a month ago and had worsening of r... | 22 |
preoperative diagnoses,1. herniated nucleus pulposus c2-c3.,2. spinal stenosis c3-c4.,postoperative diagnoses,1. herniated nucleus pulposus c2-c3.,2. spinal stenosis c3-c4.,procedures,1. anterior cervical discectomy, c3-c4, c2-c3.,2. anterior cervical fusion, c2-c3, c3-c4.,3. removal of old instrumentation, c4-c... | 23 |
title of operation:, left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,indication for surgery: , the patient is a patient well known to my service. she came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. i took her t... | 38 |
preoperative diagnosis: , cervical myelopathy, c3-4, secondary to stenosis from herniated nucleus pulposus, c3-4.,postoperative diagnoses: , cervical myelopathy, c3-4, secondary to stenosis from herniated nucleus pulposus, c3-4.,operative procedures,1. anterior cervical discectomy with decompression, c3-4.,2. arthrod... | 27 |
history of present illness: ,the patient is a 78-year-old woman here because of recently discovered microscopic hematuria. history of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. the patient has no new joint pains; however, she d... | 21 |
preoperative diagnoses: ,1. right lower extremity radiculopathy with history of post laminectomy pain.,2. epidural fibrosis with nerve root entrapment.,postoperative diagnoses: ,1. right lower extremity radiculopathy with history of post laminectomy pain.,2. epidural fibrosis with nerve root entrapment.,operation... | 38 |
principal diagnosis:, knee osteoarthrosis.,principal procedure: , total knee arthroplasty.,history and physical:, a 66-year-old female with knee osteoarthrosis. failed conservative management. risks and benefits of different treatment options were explained. informed consent was obtained.,past surgical history: , ... | 27 |
history of present illness:, the patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. he has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fr... | 25 |
chief complaint:, here with a concern of possibly issues of short-term memory loss. she is under exceeding amount of stress over the last 5 to 10 years. she has been a widow over the last 11 years. her husband died in an mva from a drunk driver accident. she had previously worked at the bank in conway springs in n... | 5 |
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... | 9 |
chief complaint:, well-child check and school physical.,history of present illness:, this is a 9-year-old african-american male here with his mother for a well-child check. mother has no concerns at the time of the visit. she states he had a pretty good school year. he still has some fine motor issues, especially ... | 29 |
procedure:, flexible bronchoscopy.,preoperative diagnosis (es):, chronic wheezing.,indications for procedure:, evaluate the airway.,description of procedure: ,this was done in the pediatric endoscopy suite with the aid of anesthesia. the patient was sedated with sevoflurane and propofol. one ml of 1% lidocaine was used... | 3 |
reason for catheterization:, st-elevation myocardial infarction.,procedures undertaken,1. left coronary system cineangiography.,2. right coronary system cineangiography.,3. left ventriculogram.,4. pci to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm vision bare-metal stents postdilated with a 3.75-mm noncom... | 38 |
preoperative diagnosis: , foreign body, right foot.,postoperative diagnosis: , foreign body in the right foot.,procedure performed:, excision of foreign body, right foot and surrounding tissue.,anesthesia: , tiva and local.,history:, this 41-year-old male presents to preoperative holding area after keeping himself n.... | 27 |
chief complaint:, itchy rash.,history of present illness: , this 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. no facial swelling. no tongue or lip swelling. no shortness of breat... | 15 |
history of present illness: , this is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent pta of right leg, admitted to the hospital because of swelling of the right hand and left foot. ... | 5 |
preoperative diagnosis: ,left breast mass with abnormal mammogram.,postoperative diagnosis:, left breast mass with abnormal mammogram.,procedure performed:, needle-localized excisional biopsy of the left breast.,anesthesia:, local with sedation.,complications: , none.,specimen: , breast mass.,disposition: , the pati... | 38 |
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 w... | 33 |
history of present illness:, the patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. she states that she has not voided in the last 24 hour... | 12 |
physical examination,general appearance: , well developed, well nourished, in no acute distress.,vital signs:, ***,skin: ,inspection of the skin reveals no rashes, ulcerations or petechiae.,heent:, the sclerae were anicteric and conjunctivae were pink and moist. extraocular movements were intact and pupils were equ... | 15 |
findings:,axial scans were performed from l1 to s2 and reformatted images were obtained in the sagittal and coronal planes.,preliminary scout film demonstrates anterior end plate spondylosis at t11-12 and t12-l1.,l1-2: there is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no poste... | 22 |
preoperative diagnosis:, recurrent right upper quadrant pain with failure of antacid medical therapy.,postoperative diagnosis: , normal esophageal gastroduodenoscopy.,procedure performed:, esophagogastroduodenoscopy with bile aspirate.,anesthesia: , iv demerol and versed in titrated fashion.,indications: , this 41-ye... | 38 |
cc: ,motor vehicle-bicycle collision.,hx:, a 5 y/o boy admitted 10/17/92. he was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. first responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. he had bilateral decorticate posturing ... | 22 |
procedure: , skin biopsy, scalp mole.,indication: ,a 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,procedure note: , the patient's scalp hair was removed with:,1. k-y jelly.,2. betadine prep locally.,3. a 1% lidocaine with epinephrine local instilled.,4. a 3 mm punch ... | 38 |
history:, a 69-year-old female with past history of type ii diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. the patient was status post coronary artery bypass surgery aortic valve repair at shadyside hospital. the patient subsequently developed cva. she also developed thrombosis of the righ... | 5 |
admission diagnoses:,1. atypical chest pain.,2. nausea.,3. vomiting.,4. diabetes.,5. hypokalemia.,6. diarrhea.,7. panic and depression.,8. hypertension.,discharge diagnoses:,1. serotonin syndrome secondary to high doses of prozac.,2. atypical chest pain with myocardial infarction ruled out.,3. diabetes melli... | 15 |
chief complaint:, pressure decubitus, right hip.,history of present illness:, this is a 30-year-old female patient presenting with the above chief complaint. she has a history of having had a similar problem last year which resolved in about three treatments. she appears to have residual from spina bifida, thus spendin... | 15 |
preoperative diagnoses:,1. extruded herniated disc, left l5-s1.,2. left s1 radiculopathy (acute).,3. morbid obesity.,postoperative diagnoses:,1. extruded herniated disc, left l5-s1.,2. left s1 radiculopathy (acute).,3. morbid obesity.,procedure performed: , microscopic lumbar discectomy, left l5-s1.,anesthesia: ,... | 38 |
current history:, a 94-year-old female from the nursing home with several days of lethargy and anorexia. she was found to have evidence of uti. she also has renal insufficiency and digitalis toxicity. she is admitted for further treatment.,past medical history, social history, family history, physical examination c... | 15 |
preoperative diagnosis:, rotator cuff tear, right shoulder.,postoperative diagnoses:,1. massive rotator cuff tear, right shoulder.,2. near complete biceps tendon tear, right shoulder.,3. chondromalacia of glenohumeral joint, right shoulder.,4. glenoid labrum tear, right shoulder.,procedure performed: ,1. arthros... | 38 |
mr. xyz forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. for all these reasons, this was not really under the best circumstances and i had to curtail the amount of time i spent trying to get a history bec... | 27 |
preoperative diagnoses: , phimosis and adhesions.,postoperative diagnoses: ,phimosis and adhesions.,procedures performed: , circumcision and release of ventral chordee.,anesthesia: ,local mac.,estimated blood loss: , minimal.,fluids: , crystalloid. the patient was given antibiotics preop.,brief history: , this is a ... | 38 |
procedure performed: , excisional breast biopsy with needle localization.,anesthesia:, general.,procedure: , after informed consent was obtained, the patient was brought to the radiology suite where needle localization was performed with mammographic guidance. i reviewed the localizing films with the radiologist, and... | 38 |
final diagnoses,1. morbid obesity, status post laparoscopic roux-en-y gastric bypass. ,2. hypertension. ,3. obstructive sleep apnea, on cpap.,operation and procedure: , laparoscopic roux-en-y gastric bypass.,brief hospital course summary: ,this is a 30-year-old male, who presented recently to the bariatric center f... | 10 |
End of preview. Expand in Data Studio
No dataset card yet
- Downloads last month
- 8