record_id string | speciality string | name string | description string | chunk_index int64 | transcription string | audio audio | duration_s float64 | voice string | speed float64 | lang_code string | keywords list | is_augmented bool | snr_db float32 | noise_layers int32 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
d122a64d | Obstetrics / Gynecology | D&C & Tubal Pregnancy Removal | Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy. | 5 | A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated using Hank dilators up to a #10. A sharp curette was then introduced and curettage was performed obtaining a mild amount of ti... | 18.225 | bm_fable | 1 | a | [
"obstetrics / gynecology",
"lower quadrant mass",
"tubal pregnancy",
"pelvic adhesions",
"laparoscopy",
"salpingectomy",
"ectopic pregnancy",
"abdominal wall",
"pregnancy"
] | true | 5.636878 | 2 | |
6279b623 | Neurology | Dural AVM | Patient with episode of lightheadedness and suddenly experienced vertigo. | 6 | This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. | 19.15 | am_echo | 1 | a | [
"neurology",
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"cerebellar hemisphere",
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] | false | null | 0 | |
c84ba437 | Cardiovascular / Pulmonary | Thromboendarterectomy | Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior... | 4 | The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. | 18.65 | af_sarah | 1 | a | [
"cardiovascular / pulmonary",
"cabg",
"thromboendarterectomy",
"carotid artery",
"coronary artery bypass",
"mammary",
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"papaverine-soaked",
"running prolene suture",
"cardiopulmonary bypass",
"internal carotid",
"running prolene",
"prolene suture",
"carotid",
"sutured",
"arter... | true | 1.94828 | 2 | |
9a5a2f35 | SOAP / Chart / Progress Notes | Gen Med SOAP - 8 | Patient today with multiple issues. | 0 | SUBJECTIVE: I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had signifi... | 21.325 | af_sky | 1 | a | [
"soap / chart / progress notes",
"multiple issues",
"atrial fibrillation",
"gross hematuria",
"multiple",
"bph",
"fibrillation",
"hematuria"
] | true | 11.291286 | 3 | |
90ed4ad5 | Urology | Foul-Smelling Urine | Foul-smelling urine and stomach pain after meals. | 4 | Also referred her for a barium swallow series to rule out a stricture. 4. Ortho Tri-Cyclen Lo. | 6.75 | af_sky | 1 | a | [
"urology",
"foul-smelling urine",
"stomach pain",
"uti",
"gerd",
"dysphagia",
"contraception"
] | false | null | 0 | |
5b1ff9e1 | Urology | Prostatectomy - Radical Retropubic | Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer. | 2 | The patient was then taken into the operating room after which general LMA anesthesia was administered. The patient was shaved and then prepped using Betadine solution. A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain. A midline infraumbilical incision was performed. The rectus fa... | 22.775 | af_nova | 1 | a | [
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"adenocarcinoma",
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"pelvic lymph node dissection",
"perivesical",
"prostatectomy",
"retropubic",
"urethra",
"radical retropubic prostatectomy",
"lymph node dissection",
"dors... | true | 7.763517 | 2 | |
d78dabd5 | Chiropractic | Chiropractic IME - 1 | Chiropractic IME with answers to questions from Insurance Company. | 46 | 9. If findings of permanent impairment exist, do you expect there will be periods of waxing and waning of symptoms that may result in additional medical services and/or periods of temporary disability? Please provide your best assessment as to what can be reasonably anticipated. | 15.925 | am_onyx | 1 | a | [
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"lower back pain",
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"... | true | 5.563713 | 3 | |
24360325 | Pain Management | Superior Gluteal Nerve Block | Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome. | 2 | Aseptic technique was observed at all times, and there were no complications noted. INJECTATE INCLUDED: Methyl Prednisolone (DepoMedrol): 20 mg Ketorolac (Toradol): 6 mg Sarapin: 1 cc Bupivacaine (Marcaine): Q.S. 2 cc. The procedures, above were performed for diagnostic, as well as therapeutic purposes. | 20.975 | bf_emma | 1 | a | [
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"gluteus medius muscle",
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"gluteus medius",
"nerve block",
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"block",
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"gluteal"
] | false | null | 0 | |
0240172d | Cosmetic / Plastic Surgery | Capsulotomy & Flat Advancement, Left Breast | Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery. | 7 | The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2-0 Biosyn. This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferio... | 19.05 | af_jessica | 1 | a | [
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... | true | 11.035487 | 2 | |
ff8851fc | Consult - History and Phy. | Erythema Nodosum - Consult | The patient presents for a followup for history of erythema nodosum. | 43 | Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies. | 16.65 | am_fenrir | 1 | a | [
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d1aaf4e2 | Consult - History and Phy. | Dietary Consult - Gestational Diabetes | Dietary consultation for gestational diabetes. | 11 | The meal plan is as follows: breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings. Recommend patient include a solid protein with each of her meals as well as with her sna... | 21.75 | af_kore | 1 | a | [
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"dietary... | true | -1.997375 | 2 | |
d2b1352a | Urology | Bladder Instillation | Bladder instillation for chronic interstitial cystitis. | 8 | She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment,... | 23.25 | bm_george | 1 | a | [
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] | true | 3.360487 | 3 | |
8d24d701 | Surgery | Esophagogastroduodenoscopy - 11 | Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy. | 3 | At this time, the patient as well complained of epigastric discomfort and nausea. This pain was similar to her previous pain. Bile was aspirated with a trap to enable the collection of the fluid. This fluid was then sent to lab for evaluation for crystals. | 16.275 | am_adam | 1 | a | [
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"kinevac",
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"esophagogastroduodenoscopy",
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] | true | 1.385032 | 1 | |
de0898c2 | Orthopedic | Pinning - Hip | Revision and in situ pinning of the right hip. | 1 | HISTORY AND PHYSICAL: The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluor... | 18.4 | bm_daniel | 1 | a | [
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] | false | null | 0 | |
ff8851fc | Consult - History and Phy. | Erythema Nodosum - Consult | The patient presents for a followup for history of erythema nodosum. | 41 | PLANS: We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies. We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly. We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid s... | 19.975 | am_fenrir | 1 | a | [
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0cd8082a | IME-QME-Work Comp etc. | Back Injury IME | Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation. | 10 | The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms. PHYSICAL EXAMINATION: The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bend... | 23.125 | bm_lewis | 1 | a | [
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] | true | 12.718214 | 3 | |
246b6307 | Surgery | Arthroscopy & Chondroplasty | Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome. | 11 | It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet. She was transferred to recovery room in apparent stable and satisfactory condition. Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint. | 20.125 | af_heart | 1 | a | [
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"chondromalacia",
"patellofemoral"
] | false | null | 0 | |
0f06d94b | Surgery | Fiberoptic Flexible Bronchoscopy | Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe. Right hyoid mass, rule out carcinomatosis. Chronic obstructive pulmonary disease. Changes consistent with acute and chronic bronchitis. | 18 | At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. | 14.35 | bf_emma | 1 | a | [
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"endobronchial",
"oropharynx"... | true | 6.7753 | 1 | |
4ac38cab | Surgery | Lobectomy - Left Lower | Left lower lobectomy. | 4 | Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed. The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. | 19.425 | af_sarah | 1 | a | [
"surgery",
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"electrocautery",
"endo gia stapler",
"subcutaneous drain",
"endotracheal",
"subcutaneous",
"lobectomy"
] | true | 10.89387 | 1 | |
8f6fdaf5 | General Medicine | Elbow Pain - Consult | Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia. | 3 | HEENT: TMs and canals are normal. There is no Battle sign. NECK: Supple. He has good range of motion. Spinal processes are normal to palpation. LUNGS: Clear. CARDIAC: Regular rate. No murmurs or rubs. EXTREMITIES: Left elbow is tender. He does not wish to move it at all. Shoulder and clavicle are within normal limits. ... | 24.775 | af_bella | 1 | a | [
"general medicine",
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"fracture of the humerus",
"neurapraxia",
"fracture",
"elbow"
] | true | 14.463549 | 3 | |
2ef3f840 | Cardiovascular / Pulmonary | Exercise Stress Test - 1 | A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram. | 3 | IMPRESSION: 1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate. 2. Resting hypertension with appropriate response of blood pressure to exercise. These results have been discussed with the patient. Other management as per the hospital-based internal medicine s... | 23.35 | bf_emma | 1 | a | [
"cardiovascular / pulmonary",
"ecg/echocardiogram",
"exercise stress test",
"ecg",
"wall motion abnormalities",
"target heart rate",
"hypertension",
"echocardiogram"
] | true | 14.558593 | 3 | |
b1f3a938 | Gastroenterology | Diverticulectomy & Laparotomy | Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet. | 9 | The instruments were then removed. The abdomen was then deflated. Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis. The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery. | 17.05 | af_nova | 1 | a | [
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"abdominal wall",
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"divert... | true | 6.871793 | 2 | |
27fc9afb | Gastroenterology | Laparoscopic Cholecystectomy - 8 | Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge. | 4 | The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg. The epigastric and right subcostal trocars were placed under direct vision. The right upper quadrant was well visualized. The gallbladder was no... | 26 | bm_george | 1 | a | [
"gastroenterology",
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"abdominal",
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] | true | 11.033207 | 2 | |
d3405910 | Radiology | Fetal Anatomical Survey | The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. | 5 | The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insert... | 26.275 | af_bella | 1 | a | [
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] | true | -0.340042 | 1 | |
32aae84a | Orthopedic | Symes Amputation - Hallux | Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx. | 7 | Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. | 18.475 | bf_lily | 1 | a | [
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] | true | 2.914931 | 3 | |
07a80c4c | Ophthalmology | Diplopia | He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again. | 10 | His father had colon cancer. He is unaware of any family members with neurological disorders. REVIEW OF SYSTEMS: A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit. | 17.725 | af_kore | 1 | a | [
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"myasthenia",
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] | true | 3.904587 | 1 | |
fc931d1f | Surgery | Tarsectomy | Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot. | 2 | The patient desires surgical treatment at this time. PROCEDURE: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. | 16.25 | am_liam | 1 | a | [
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] | true | 12.499663 | 3 | |
4d920d7e | Orthopedic | Cemented Hemiarthroplasty & Biopsy | Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment. | 17 | Once again, 0 neck length trial bipolar head was inserted over the trunnion. It was reduced and range of motion and stability was satisfactory. I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. | 21.725 | am_michael | 1 | a | [
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] | true | -2.00667 | 2 | |
a391aacd | Orthopedic | Bunion & Pes Planovalgus Deformity | Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet. | 8 | 2. Pes planovalgus deformity, bilateral feet. PLAN/TREATMENT: 1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a dec... | 22.175 | bf_alice | 1 | a | [
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] | true | 9.57948 | 3 | |
81236c71 | Obstetrics / Gynecology | Intrauterine Pregnancy - Discharge Summary | Intrauterine pregnancy at term with previous cesarean. Desired sterilization. Status post repeat low transverse cesarean and bilateral tubal ligation. | 2 | PHYSICAL EXAMINATION GENERAL: An alert gravid woman in no distress. ABDOMEN: Gravid, nontender, non-irritable, with an infant in the vertex presentation. Estimated fetal weight was greater than 10 pounds. | 13.2 | am_onyx | 1 | a | [
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] | false | null | 0 | |
cf0c64ac | Urology | HPV Consult | Likely molluscum contagiosum (genital warts) caused by HPV. It is not clear where this came from but it is most likely sexually transmitted. | 8 | He is instructed that he should use protected sex from this point on in order to try and limit the transmission. Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work. I also offered him C02 laser therapy for the genital warts, which is an outp... | 21.1 | af_heart | 1 | a | [
"urology",
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"molluscum contagiosum",
"genital warts",
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] | true | 0.384909 | 2 | |
1c6ae141 | SOAP / Chart / Progress Notes | Urinary Retention - Followup | The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse. | 1 | No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse. | 15.025 | am_puck | 1 | a | [
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"prolapse",
"vaginal",
"incontinence"
] | false | null | 0 | |
ee85fbf8 | Psychiatry / Psychology | Neuropsychological Evaluation - 3 | Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decision... | 45 | As mentioned above, he had a number of repetitions and difficulty organizing information meaningfully on memory tasks. Taken together, these results suggest mild weaknesses in aspects of frontal lobe functioning. MOTOR FUNCTIONING: The patient performed in the average range with both of his right dominant hand and left... | 24.425 | af_bella | 1 | a | [
"psychiatry / psychology",
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"attention",
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"beery buktenica developmental test",
"neuropsychological evaluation",
"premorbid functioning",
"cognitive functioning",
"verbal learning",
"verbal... | true | 4.056994 | 2 | |
b5f59ae9 | Orthopedic | Discharge Summary - Hip Surgery | A 47-year-old female with a posttraumatic AV in the right femoral head. | 1 | POSTOP COMORBIDITIES: Postop acute blood loss anemia requiring transfusion and postop pain. PROCEDURES DURING THIS HOSPITALIZATION: Right total hip arthroplasty and removal of hardware. CONSULTS: Acute pain team consult. DISPOSITION: Home. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: For details, please refer to cli... | 26.675 | am_michael | 1 | a | [
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"discharge"
] | true | 13.704668 | 3 | |
f3b3c9c9 | Neurosurgery | Anterior Cervical Discectomy & Osteophytectomy | Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation | 0 | PREOPERATIVE DIAGNOSES 1. Cervical radiculopathy, C5-C6 and C6-C7. 2. Symptomatic cervical spondylosis, C5-C6 and C6-C7. 3. Symptomatic cervical stenosis, C5-C6 and C6-C7. 4. Symptomatic cervical disc herniations, C5-C6 and C6-C7. POSTOPERATIVE DIAGNOSES 1. Cervical radiculopathy, C5-C6 and C6-C7. 2. Symptomatic cervic... | 22.35 | am_eric | 1 | a | [
"neurosurgery",
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"interbody fusion",
"prosthetic interbody fusion device",
"arthrodesis",
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"cervical lordosis",
"... | true | 8.241055 | 3 | |
2904f984 | Obstetrics / Gynecology | Tubal Ligation | Laparoscopic bilateral tubal ligation with Falope rings. | 3 | Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring. The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization. An attempt was made to close the fascia with a figure-of-e... | 18.925 | am_liam | 1 | a | [
"obstetrics / gynecology",
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"laparoscopic bilateral tubal ligation with falope rings",
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"tubal ligation",
"falope rings",
"anesthesia",
"tubal",
"ligation",
"falope"... | true | 11.885279 | 1 | |
6c9baaae | Orthopedic | Arthroscopy, Arthrotomy, Bankart lesion repair | Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures). | 19 | Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique. This brought the capsule right up to the edge of the glenoid rim. | 14.275 | af_heart | 1 | a | [
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"absorbable anchors",
"anterior instability",
"chondromalacia",
"superior labrum",
"glenoid erosion",
"glenoid rim",
"external... | true | 3.271295 | 2 | |
4ebad8ac | Surgery | ORIF & Cervical Fusion | Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3. | 14 | The subcutaneous tissues were closed using a #2-0 Vicryl suture. The dermal edges were approximated using staples. The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately. The patient was subsequently released with a Mayfield contraption and ro... | 22.65 | af_alloy | 1 | a | [
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"spinal",
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"instrumentation"
] | true | 5.237332 | 2 | |
bbbe71ab | Surgery | Laparoscopic Cholecystectomy & Appendectomy | Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. | 7 | The appendix was identified and window was made in the mesoappendix at the base. This was amputated with an Endo-GIA stapler. The mesoappendix was divided with an Endo-GIA vascular stapler. This was placed in another Endocatch bag. The abdomen was then irrigated. Hemostasis was satisfactory. Both the appendix and gallb... | 26.45 | bm_lewis | 1 | a | [
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"appendix",
"cholelithiasis",
"endotracheal",
"laparoscopic",
"cholecystectomy",
"gallbladder",
"duct"
] | false | null | 0 | |
efc612cd | Orthopedic | Laminectomy & Foraminotomy & Cervical Fusion | Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft. | 22 | A drain was left in the posterior cervical spine. The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed. The patient was taken to the recovery room in good condition. | 11.45 | af_river | 1 | a | [
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"cervical spine",
"nerve roots",
"cancellous bone",
"bone graft",
"spinous process",
"fusion",
"iliac",
"cervical"... | true | 2.613579 | 1 | |
f35fa49c | Surgery | I&D & Open Reduction - Forearm | Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast. | 4 | All questions were answered and they signed the consent for procedure as described. DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and general anesthesia was achieved. The right forearm was inspected. There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the m... | 19.6 | am_puck | 1 | a | [
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"forearm fracture",
"anatomic alignment",
"arm cast",
"puncture wound",
"tourniquet",
"i&d",
"fra... | true | 5.526861 | 2 | |
243cb73e | Cardiovascular / Pulmonary | Mediastinal Exploration & Right Atrium Repair | The patient had undergone mitral valve repair about seven days ago. | 4 | An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. | 13.85 | am_eric | 1 | a | [
"cardiovascular / pulmonary",
"mitral valve repair",
"exploration",
"median sternotomy chest incision",
"pericardial",
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"pacing wires",
"cardiac tamponade",
"chest tubes",
"mitral valve",
"valve repair",
"mediastinal",
"mitral",
"wires",
"atrium",
"repair"
] | true | -2.372722 | 1 | |
39fce11a | Radiology | Intensity-Modulated Radiation Therapy Simulation | Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. | 2 | Appropriate doses are selected, both for the target, as well as constraints for organs at risk. Inverse treatment planning is performed by the physics staff under my supervision. These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality as... | 18.125 | am_echo | 1 | a | [
"radiology",
"target volume",
"intensity modulated radiation therapy",
"simulation"
] | true | 9.537569 | 2 | |
9b106fd1 | Surgery | Cystourethroscopy & Retrograde Pyelogram - 1 | Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria. | 1 | ANESTHESIA: Sedation. SPECIMEN: Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies. INDICATION: The patient is a 74-year-old male who was initially seen in the office with hematuria. He was then brought to the hospital for other medical problems and found to... | 19.85 | bm_daniel | 1 | a | [
"surgery",
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"ureteropelvic junction obstruction",
"cystourethroscopy",
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"renal biopsy",
"double-j",
"ureteral stent placement",
"ureteropelvic junction",
"flexible scope",
"papillary mass",
"ureteral stent",
"re... | true | -1.827888 | 2 | |
171748c7 | Consult - History and Phy. | Dietary Consult - 1 | Elevated cholesterol and is on medication to lower it. | 5 | 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. | 13.85 | af_aoede | 1 | a | [
"consult - history and phy.",
"vegetarian",
"lipids",
"cholesterol intake",
"elevated cholesterol",
"losing weight",
"body weight",
"dietary",
"cholesterol"
] | false | null | 0 | |
4ae7b25b | Orthopedic | MRI Elbow - 2 | MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm. | 2 | The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel. There is no accessory muscle within the cubital tunnel. The common flexor tendon origin is normal. Normal ulnar collateral ligamentous co... | 19.1 | am_puck | 1 | a | [
"orthopedic",
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"ulnar nerve",
"elbow",
"edema",
"olecranon",
"inflammation",
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"ulnar",
... | true | 14.44256 | 2 | |
e9a0999b | Surgery | Frontotemporoparietal Craniotomy | Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome. | 2 | The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder. The right side of the head was shaved, thoroughly prepped and draped, a large ? | 10.725 | bm_daniel | 1 | a | [
"surgery",
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"herniation",
"subdural",
"temporalis",
"frontotemporoparietal",
"hematoma"
] | false | null | 0 | |
2bfb699f | Consult - History and Phy. | Chronic Sinusitis | Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. | 4 | She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. | 16.55 | bm_fable | 1 | a | [
"consult - history and phy.",
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"mucosal thickening",
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"nasal septum deviation",
"postnasal drip",
"nasal septum",
"turbinate hypertrophy",
"turbinate",
... | true | -0.12338 | 2 | |
58fa4cb4 | Neurology | Moyamoya Disease | Cerebral Angiogram - moyamoya disease. | 1 | For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on. She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right... | 20.875 | af_bella | 1 | a | [
"neurology",
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"angiogram",
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"mca",
"moya moya disease",
"pronator drift",
"hemiparesis",
"headache",
"moya"
] | true | 1.912933 | 1 | |
5f2a5076 | Surgery | Bunionectomy & Flexor Tenotomy | Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes. | 11 | The capital fragment was shifted laterally and impacted into the head. A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy. A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique. A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw. | 19.975 | am_puck | 1 | a | [
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"interphalangeal joint arthroplasty",
"distal interphalangeal joint",
"interphalangeal joint",
"flexor tenotomy",
"proximal interphalang... | true | -1.973186 | 3 | |
2319d43c | Surgery | Chest Tube Removal | Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound. | 0 | PREOPERATIVE DIAGNOSIS: Bilateral pleural effusion. POSTOPERATIVE DIAGNOSIS: Bilateral pleural effusion. PROCEDURE PERFORMED: Removal of bilateral #32-French chest tubes with closure of wound. COMPLICATIONS: None. INDICATIONS FOR PROCEDURE: The patient is a 66-year-old African-American male who has been in the intensiv... | 24.4 | af_alloy | 1 | a | [
"surgery",
"serous drainage",
"bilateral pleural effusion",
"pleural effusion",
"chest tubes",
"effusion",
"pleural",
"chest"
] | true | 2.643051 | 2 | |
bc263e4a | General Medicine | Nausea & Vomiting - ER Visit | She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission. | 1 | PAST OBSTETRICAL HISTORY: This is her first pregnancy. PAST GYNECOLOGICAL HISTORY: Not pertinent. While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2. | 18.175 | bf_isabella | 1 | a | [
"general medicine",
"iv hydration",
"elevated alt",
"emergency",
"nausea",
"vomiting"
] | false | null | 0 | |
062f5149 | Neurosurgery | Pterional Craniotomy | Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma. | 13 | The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a Dur... | 19.425 | af_sky | 1 | a | [
"neurosurgery",
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"pterional craniotomy",
"bone flap",
"bipolar coagulation",
"arteriovenous",
"pterional",
"malformation",
"hematoma",
"intracerebral"
] | true | 5.691249 | 1 | |
783660da | Discharge Summary | Knee Osteoarthrosis - Discharge Summary | A 66-year-old female with knee osteoarthrosis who failed conservative management. | 2 | She tolerated this well. She was taken to the recovery room. After uneventful recovery room course, she was brought to regular surgical floor. Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated. Routine postoperative antibiotics were administered. Hemovac drain was discontinued on postopera... | 23.25 | bm_daniel | 1 | a | [
"discharge summary",
"total knee arthroplasty",
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"knee arthroplasty",
"physical therapy",
"knee osteoarthrosis",
"arthroplasty",
"osteoarthrosis",
"knee"
] | false | null | 0 | |
701f891f | Surgery | Hemivulvectomy | Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy. | 1 | Biopsy obtained by The patient confirmed recurrence. In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ. FINDINGS: During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris. No other obvious... | 19.55 | am_liam | 1 | a | [
"surgery",
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"wide local excision",
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"melanoma",
"woods lamp",
"recurrent vulvar melanoma",
"anterior hemivulvectomy",
"vulvar",
"labia",
"radical",
"skinning"
] | true | 6.143017 | 2 | |
fae60767 | Podiatry | Bunionectomy & Osteotomy | Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation. | 11 | A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head. Again, an excellent rigid fixation was obtained and the screws were tight. The temporary fixation was removed. A medial overhanging bone was resected with a sagittal saw. | 18.3 | af_jessica | 1 | a | [
"podiatry",
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"metatarsophalangeal joint",
"pneumatic ankle",
"metatarsal head",
"foot",
"toe",
"sagittal",
"metatarsal"
] | true | 3.793644 | 2 | |
5d28917c | Chiropractic | Knee & Back Pain | Evaluation for chronic pain program | 17 | IMPRESSION AND PLAN: Status post left knee injury with subsequent knee replacement and continued chronic painful left knee, mostly mechanical low back pain without evidence of radicular features. I think she may have a small sensory neuralgia of her left common peroneal nerve and has ongoing pain over her tibial platea... | 19.075 | am_onyx | 1 | a | [
"chiropractic",
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"oswestry pain inventory",
"vas pain scale",
"anterior aspect",
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"femoral nerve area",
"lateral tibial",
"numbness and tingling",
"physical therapy",
"tibial plateau",
"pins and needles sensation",
"fibular head",
"knee",
"plateau",
"... | true | 13.61827 | 2 | |
6da8ce25 | Urology | Elevated PSA - H&P | Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream. | 2 | SOCIAL HISTORY: Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use. FAMILY HISTORY: Patient admits a family history of gout attacks associated with father. REVIEW OF SYSTEMS: Unremarkable with exception of chief complaint. | 20.175 | bf_emma | 1 | a | [
"urology",
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"prostate specific antigen",
"ultrasound of prostate",
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"dribbling urine",
"urinary hesitancy",
"urine stream",
"nocturia",
"bladder",
"urinary",
"serum",
"tenderness"
] | false | null | 0 | |
45321cc2 | Neurology | TIA & Lumbar Stenosis | Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale. | 9 | General: This is a pleasant white male in no acute distress. HEENT: He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness. Neck: Supple. Chest: Clear to auscultation. Heart: There are no bruits present. Extremities: Extremities are warm and dry. Distal pulses are full. The... | 20.225 | af_kore | 1 | a | [
"neurology",
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"ct myelogram",
"extremity weakness",
"cranial nerves",
"ct angiogram",
"weakness",
"lumbar",
"stenosis",
"incontinence"
] | true | 6.452556 | 3 | |
ebd5d885 | Surgery | Arthroscopy - Glenoid Labrum | Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear o... | 11 | Interrupted #4-0 nylon was utilized for portal closures. Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing. The patient's arm was placed in an arm sling. He was transferred to his cart and to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is quite gua... | 20.275 | am_eric | 1 | a | [
"surgery",
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"shoulder",
"tear",
"arthroscopy",
"arthroscopic",
"tenotomy",
"glenohumeral",
"... | false | null | 0 | |
0979457c | Gastroenterology | Constipation - 1 | Patient complains of constipation. Has not had BM for two days. | 0 | Patient complains of constipation, severe at times. Has not had BM for two days. Denies chest pain. Has been ambulating well. No history suggestive of angina. Will be seeing cardiologist this afternoon. Patient was informed by Dr. ABC that he does not need sleep study as per patient. PHYSICAL EXAMINATION: General: Plea... | 27 | bm_george | 1 | a | [
"gastroenterology",
"constipation",
"bm",
"milk of magnesia",
"suppository",
"dulcolax",
"fleet enema"
] | false | null | 0 | |
eeacaac2 | Cardiovascular / Pulmonary | Pulmonary Atresia | The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. | 5 | PROCEDURE: After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized... | 20.275 | af_sarah | 1 | a | [
"cardiovascular / pulmonary",
"pulmonary atresia",
"vacterl",
"glenn shunt",
"fontan hemodynamics",
"ventricle outflow tract",
"bidirectional glenn shunt",
"superior vena cava",
"inferior vena cava",
"ventricular septum",
"tricuspid valve",
"pulmonary artery",
"fontan fenestration",
"coron... | true | 1.783951 | 3 | |
e139844f | Gastroenterology | Exploratory Laparotomy - 1 | Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent. | 13 | Subq tissue was copiously irrigated and the staples on the skin. The iodoform packing was placed within the old ostomy site and then the staples on the skin as well. The patient did tolerate the procedure well and will be followed during the hospitalization. The left ureteral stent was removed at the end of the procedu... | 17.875 | am_onyx | 1 | a | [
"gastroenterology",
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"flexible sigmoidoscopy",
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"abdominal wall",
"immediately",
"adhesions",
"colostomy",
"sigmoidoscopy",
"bowel",
"anastomosis",
... | false | null | 0 | |
03e979d9 | Orthopedic | MRI Ankle - 1 | Patient with right ankle pain. | 12 | Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear. Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon. | 11 | am_onyx | 1 | a | [
"orthopedic",
"flexor hallucis longus tendon",
"hallucis longus tendon sheath",
"anterior tibiofibular ligament",
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"hallucis longus tendon",
"longus tendon sheath",
"prominent fluid distention",
"marrow stress phenomenon",
"ligamentous complex",
"achilles tendon",
"lon... | false | null | 0 | |
ff2eb63f | Cardiovascular / Pulmonary | Cineangiography - 1 | Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. | 11 | Excellent results, 0% residual stenosis. The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels. Therefore, we will aggressively treat this patient medically with close followup as an outpatient. | 17.3 | bf_isabella | 1 | a | [
"cardiovascular / pulmonary",
"ventriculogram",
"circumflex",
"bare-metal stents",
"myocardial infarction",
"st-elevation",
"coronary system cineangiography",
"infarction",
"stents",
"cineangiography",
"stenosis"
] | false | null | 0 | |
09cd21c9 | Consult - History and Phy. | Normal Physical Exam Template - 7 | Most commonly used phrases in physical exam. | 4 | There is no tactile fremitus or egophony noted. There is no tenderness to the chest wall or ribs. There are no obvious abnormalities. The lungs are clear to auscultation. There are no wheezes, rales or rhonchi heard. There are no obvious rubs noted. CARDIOVASCULAR: There is a normal PMI on palpation. I do not hear any ... | 19.325 | bm_fable | 1 | a | [
"consult - history and phy.",
"ears",
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"neck",
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"eyes",
"gastrointestinal",
"genitourinary",
"breasts",
"lymphatics",
"musculoskeletal",
"extremities",
"skin",
"neurologic",
"psychiatric",
"normal appearing",
"physical exam",
"exa... | true | 14.141665 | 1 | |
33ded702 | Surgery | Colonoscopy & Polypectomy - 1 | Total colonoscopy and polypectomy | 3 | His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since. Representative pictures were taken throughout the entire exam. There was no other evidence any problems. On withdrawal of the scope, the same findings were noted. | 15.85 | am_liam | 1 | a | [
"surgery",
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"lateral decubitus position",
"colon",
"colonoscopy and polypectomy",
"total colonoscopy",
"colon polyp",
"colonoscopy",
"bleeding",
"colitis",
"polypectomy",
"intermittent"
] | true | 13.788606 | 1 | |
011c719d | Surgery | Stapedectomy - Argon Lasor Assisted | Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis. | 0 | PREOPERATIVE DIAGNOSIS: Bilateral progressive conductive hearing losses with probable otosclerosis. POSTOPERATIVE DIAGNOSIS: Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis. OPERATION PERFORMED: Right argon laser assisted stapedectomy. DESCRIPTION OF OPERATION: The patient wa... | 20.4 | af_river | 1 | a | [
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] | false | null | 0 | |
08382465 | SOAP / Chart / Progress Notes | Foreskin - Followup | Follow up consultation, second opinion, foreskin. | 3 | But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision. | 13.675 | bm_fable | 1 | a | [
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] | false | null | 0 | |
a616dadf | SOAP / Chart / Progress Notes | Dietary Consult - Diabetes - 2 | Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983. | 4 | Her right second and third toes lay on each other. Also, the same on her left foot. However, there was no skin breakdown. She had large bunions, medial aspect of the ball of both feet. | 12.85 | bm_lewis | 1 | a | [
"soap / chart / progress notes",
"dietary consult",
"diabetes education",
"glucose control",
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"blood glucose",
"dietary",
"diabetes"
] | true | 6.042172 | 1 | |
feeec98a | Pediatrics - Neonatal | Atopic Eczema | 1+ year, black female for initial evaluation of a lifelong history of atopic eczema. | 0 | SUBJECTIVE: This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. | 14.35 | af_sky | 1 | a | [
"pediatrics - neonatal",
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"johnson's baby oil",
"polysporin ointment",
"atopic eczema",
"eczema",
"eczematous",
"hot soapy water",
"atopic",
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] | false | null | 0 | |
2ac1ed97 | Surgery | Bronchoscopy & Foreign Body Removal | Plastic piece foreign body in the right main stem bronchus. Rigid bronchoscopy with foreign body removal. | 2 | Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea. There were some secretions but that looked okay. Got down at the level of the carina to see a foreign body flapping in the right main stem. I then used graspers to grasp to try to pull into the scope itself. | 15.75 | am_liam | 1 | a | [
"surgery",
"main stem bronchus",
"bronchoscopy",
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"foreign body removal",
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] | true | 10.474866 | 2 | |
e6a0a9b9 | Consult - History and Phy. | Comprehensive Neurological Evaluation | A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis. | 26 | Sensation: Intact to pinprick, light touch, vibration and position sense throughout. Normal stereognosis, graphesthesia, and double simultaneous stimulation DIAGNOSTIC IMPRESSION: Multiple sclerosis, ? secondary progressive versus relapsing/remitting. CASE DISCUSSION: Thank you once again for allowing me to participate... | 24.125 | af_heart | 1 | a | [
"consult - history and phy.",
"cranial nerves",
"rapid alternating movements",
"slurred speech",
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"mri scans",
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"mri scan",
"lower extremities",
"multiple sclerosis",
"mri",
"spasticity",
"neurological",
"extremities"
] | true | 8.525376 | 2 | |
d96ccaa9 | Neurology | MRI C-Spine - C5-6 Disk Herniation | MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation. | 1 | The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shoc... | 22.2 | am_fenrir | 1 | a | [
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"disk herniation",
"mri c spine",
"reflexes",
"biceps",
"mri",
"disk",
"shoulder",
"spine",
"herniation"
] | true | 0.674277 | 2 | |
cc6eb013 | Consult - History and Phy. | Lumbar Spine HNP - Consult | Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus. | 13 | Findings: degenerative disc disease L4-5 and L5-S1. Alignment: normal. Bone density: normal. Sacro-iliac joints: normal. Sacrum and coccyx: normal. Hip joints: unremarkable. PROVISIONAL DIAGNOSIS: Lumbar Spine: Herniated Nucleus Pulposus (ICD-9-CM: 722.10). RECOMMENDATIONS - TESTS: Lumbar MRI. RECOMMENDATIONS - TREATME... | 28.7 | bf_emma | 1 | a | [
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"straight leg raising",
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"lumbar spine",
"spine",
"pulposus",
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"ortho"
] | true | 13.948487 | 1 | |
378cd2ff | Radiology | Mayoview - 1 | Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction. | 4 | MYOVIEW INTERPRETATIONS FINDINGS: The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferosept... | 23.75 | bf_emma | 1 | a | [
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"angina",
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] | true | 5.680973 | 1 | |
6a6f5d3d | Physical Medicine - Rehab | EMG/Nerve Conduction Study - 1 | The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand. | 3 | Left ulnar motor and sensory and left radial sensory responses are normal. Left median F-wave is normal. NEEDLE EMG: Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. It revealed spontaneous activity in the left abductor pollicis brevis muscle. ... | 23.875 | bf_alice | 1 | a | [
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"attenuated evoked response amplitude",
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"sensory distal latency",
"attenuated evoked response",
"dorsal interosseous muscle",
... | true | 1.261545 | 2 | |
ca4653dd | Consult - History and Phy. | Attempted Suicide - Consult | 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. | 8 | 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... | 20.75 | am_liam | 1 | a | [
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"polysubstance abuse",
"attempted suicide",
"benzodiazepines",
"psychiatric",
"polysubstance",
"abuse"
] | true | -1.01428 | 2 | |
db61204a | Surgery | Radical Mastectomy - 1 | Modified radical mastectomy. An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further. | 7 | As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved. The dissection continued caudally until the entire specimen was freed and delivered from the operative field. Copious water lavage was used to remove any debris, and hemostasis was obtai... | 20.025 | am_echo | 1 | a | [
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"radical mastectomy",
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"axillary",
"incision",
"mastectomy",
"fascia",
"muscle",
"pectoralis"
] | true | 3.635621 | 1 | |
e4a0c1ef | Radiology | Ultrasound OB - 6 | Ultrasound - a 22-year-old pregnant female. | 3 | However, fetal anatomy is limited by the early age of the fetus and followup is recommended at 22-24 weeks. EDD by ultrasound measurements: 10-31-2007. | 11.95 | am_onyx | 1 | a | [
"radiology",
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"fetal"
] | false | null | 0 | |
2d8ba3bd | Nephrology | Nephrectomy - Radical (Laparoscopic) | Laparoscopic right radical nephrectomy due to right renal mass. | 7 | There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors. We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt. This exposed the retroperitoneum on the right side. The duodenum was identified and reflec... | 24.6 | af_heart | 1 | a | [
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"screw-type trocar",
"umbilicus",
"upper pole",
"urethra",
"carter thomason closure devi... | true | 1.624284 | 3 | |
fe5c0e19 | Surgery | Phacoemulsification & Cataract Extraction - 5 | Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. | 2 | The patient was brought into the operating suite after being given dilating drops. Topical 4% lidocaine drops were used. The patient was prepped and draped in the normal sterile fashion. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. This was followed by 1% nonpreserv... | 22.05 | af_alloy | 1 | a | [
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"intraocular lens implantation",
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] | true | 0.305446 | 1 | |
95101cd7 | Neurosurgery | Anterior Cervical Discectomy & Fusion - 4 | Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium). | 16 | The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur. The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4. | 19.725 | bf_lily | 1 | a | [
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"vitoss",
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"anterior cervical discectomy",
"anterior cervical",
"herniated",
"cerv... | true | 13.49691 | 1 | |
63041094 | Psychiatry / Psychology | Psychiatric Discharge Summary - 1 | Discharge summary of a patient with mood swings and oppositional and defiant behavior. | 1 | The attending psychiatrist provided evaluation for and management of psychotropic medications and collaborated with the treatment team. The clinical therapist facilitated individual, group, and family therapy at least twice per week. COURSE IN HOSPITAL: During his hospitalization, the patient was seen initially as very... | 21.55 | am_eric | 1 | a | [
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"homicidal ideation",
"impulsive behavior",
"oppositional behavior",
"psychoeducational",
"ps... | true | 12.090158 | 2 | |
3963bb88 | Consult - History and Phy. | Neuropsychological Evaluation - 5 | The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. | 7 | Her weight was 188 pounds. Her pain score was 0/10. Her general exam was completely unremarkable. Her neurological examination showed subtle weakness in her left arm due to discomfort and pain. She had reduced vibration sensation in her left ankle and to some degree in her right foot. There was no ataxia. She was able ... | 23.025 | af_aoede | 1 | a | [
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"positional vertigo",
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"neurology consultation",
"tunnel vision",
"vestibular migraine",
"migraine symptoms",
"headaches",
"photophob... | true | 14.42367 | 2 | |
d7e7f4fa | Podiatry | Neuroma Excision | Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot. | 1 | Also, 0.5 mL dexamethasone phosphate (4 mg/mL). INDICATIONS: Please see dictated H&P for specifics. PROCEDURE: After proper identification was made, the patient was brought to the operating room and placed on the table in supine position. The patient was then placed under general anesthesia. A local block was then inje... | 24.775 | bf_isabella | 1 | a | [
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"pneumatic tourniquet",
"morton's neuroma",
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"neuroma",
"foot",
"anesthesia"
] | true | -1.068426 | 2 | |
94dd94c1 | Orthopedic | I&D & Open Reduction - Forearm | Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast. | 11 | The patient was then taken to the recovery room in stable condition. | 5.2 | am_michael | 1 | a | [
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"anatomic alignment",
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"... | true | 5.639015 | 2 | |
efc5b16d | Pediatrics - Neonatal | Neuroblastoma - Consult | The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection. | 4 | Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic. PAST MEDICAL HISTORY: Reviewed as above and otherwise unchanged. FAMILY HISTORY: Reviewed and unchanged. SOCIAL HISTORY: The patient's parents continued to undergo a separation and divorce. | 19.925 | af_heart | 1 | a | [
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"histology",
"nonerythematous",
"adrenal",
"gland",
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] | true | 6.248772 | 2 | |
78873823 | Psychiatry / Psychology | Psychosocial Eval for Kidney Transplant | Psychosocial Evaluation of patient before kidney transplant. | 8 | RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM: She is close to her brother. HIGHEST LEVEL OF EDUCATION: She has 2 years of college at ABCD College. She is a licensed LVN. MILITARY SERVICE: None. EMPLOYMENT HISTORY AND PLANS: She has worked at The ABCD Hospital as a nurse in the Breast Care Center s... | 24.9 | am_michael | 1 | a | [
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"psychosocial",
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... | true | 11.813039 | 1 | |
64dcf38d | ENT - Otolaryngology | ENT Consult | Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis. | 13 | 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. | 19 | bf_isabella | 1 | a | [
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"nasal",
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"drainage",
"throat",
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] | true | -1.875825 | 3 | |
a8716d67 | Diets and Nutritions | Dietary Consult - Weight Reduction | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | 9 | I encouraged the patient to keep food records in order to better track calories consumed. I recommended low fat selections and especially those that are lower in saturated fats. Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well. This was a one-hour consultatio... | 22.375 | bf_isabella | 1 | a | [
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"low fat",
"physical activity",
"weight",
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"dietary",
"calories",
"foo... | true | 3.199271 | 2 | |
aa8946ae | Gastroenterology | ERCP | Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy. | 6 | Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn. FINDINGS: 1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken. | 18.225 | af_kore | 1 | a | [
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"ercp",
"endoscopic",
"biliary",
"pancreatic",
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"bi... | true | -2.545985 | 1 | |
3ca3b7c9 | Surgery | Phacoemulsification & Cataract Extraction | Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye. | 5 | There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given. Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid... | 24.7 | bm_lewis | 1 | a | [
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"extracapsular",
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"cataract",
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] | false | null | 0 | |
c92f6fc2 | General Medicine | ER Report - Chest Pain & Fever | A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. | 3 | She denies any rashes or skin lesions. PAST MEDICAL HISTORY: Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal ho... | 23.65 | af_nova | 1 | a | [
"general medicine",
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"hypertension",
"acute myocardial infarction",
"urinary tract infection",
"unclear etiology"
] | false | null | 0 | |
58d3f0c9 | Autopsy | Autopsy - 6 | Multiple sharp force injuries, involving chest and abdomen, multiple incised-stab wounds of the neck, and multiple incised or cutting wounds. | 5 | Identification is by toe tag and the autopsy is not material to identification. The body is not embalmed. The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be desc... | 18.875 | am_liam | 1 | a | [
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"sharp force injury",
"superficial incised wounds",
"superficial stab wound",
"cutting wounds",
"force injuries",
"incised wounds... | true | 11.718885 | 2 | |
5096fbe8 | Obstetrics / Gynecology | TAH & Salpingooophorectomy | Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse. | 1 | 2. Uterosacral ligament vault suspension. ANESTHESIA: General and spinal with Astramorph for postoperative pain. ESTIMATED BLOOD LOSS: Less than 100 cc. FLUIDS: 2400 cc. URINE: 200 cc of clear urine output. INDICATIONS: This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of ... | 16.2 | bm_fable | 1 | a | [
"obstetrics / gynecology",
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"vaginal vault prolapse",
"uterosacral ligament vault suspension",
"total abdominal hysterectomy",
"bilateral salpingooophorectomy",
"abdominal hysterectomy",
"uterosacral ligament",
"recurrent dysplasia",
"uterine procidentia",
"s... | false | null | 0 | |
170fc9a8 | Endocrinology | Diabetes Mellitus Followup | Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin. | 1 | Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks. | 17.75 | af_heart | 1 | a | [
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"diabetes mellitus",
"insulin",
"glycemic",
"fasting",
"polyuria",
"polydipsia",
"polyphagia",
"diabetes"
] | true | 11.148953 | 2 | |
a8bacead | Consult - History and Phy. | Head & Neck Cancer Consult | Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. | 2 | He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease. His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia. | 14.225 | am_onyx | 1 | a | [
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"squamous"
] | false | null | 0 | |
334b7b6c | Surgery | Radical Hysterectomy | Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy. | 8 | Tissues were divided and suture ligated. Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated. The vagina was then clamped and divided at the junction between the middle and upper third. The vaginal vault was closed with interrupted figure-of-eight stitches. Excellent hemostasis wa... | 22.6 | bf_lily | 1 | a | [
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"pelvic and obturator lymphadenectomy",
"pelvic and obturator",
"obturator lymphadenectomy",
"laparotomy",
"ovarian",
"aden... | true | 3.467397 | 1 | |
c2df9e19 | Discharge Summary | Discharge Summary - 1 | Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia. | 14 | On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech. 2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment. | 20.125 | am_fenrir | 1 | a | [
"discharge summary",
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"parietal lobe",
"blood pressure",
"discharge",
"blood",
"tortuosity",
"parietal",
"infection",... | true | 0.774612 | 1 |
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