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Emergency Room Reports

HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. The patient states that she was on the ladder on Saturday and she stepped down after the ladder. Felt some pain in her left hip. Subsequently fell injuring her left shoulder. It's unclear how long she was on the floor. She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture. Orthopedics was consulted. Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only. She presently is complaining of pain to the left shoulder. She states she also has pain to the hip with motion of the leg. She denies any numbness or paresthesias. She states prior to this, she was relatively active within her home. She does care for her daughter who has a mess. The patient denies any other injuries. Denies back pain.,PREVIOUS MEDICAL HISTORY:, Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:, Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1. PENICILLIN.,2. SULFA.,3. ACE INHIBITOR.,PRESENT MEDICATIONS,1. Lipitor 20 mg q.d.,2. Metoprolol 25 mg b.i.d.,3. Plavix 75 mg once a day.,4. Aspirin 325 mg.,5. Combivent Aerosol two puffs twice a day.,6. Protonix 40 mg q.d.,7. Fosamax 70 mg weekly.,8. Multivitamins including calcium and vitamin D.,9. Hydrocortisone.,10. Nitroglycerin.,11. Citalopram 20 mg q.d.,SOCIAL HISTORY:, She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:, Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extremities for the last several weeks. She denies endocrinopathies. Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL: The patient is alert and responsive.,EXTREMITIES: The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment. She is diffusely tender over the proximal humerus. She is unable to actively elevate her arm due to pain. The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse. She does have chronic degenerative change to the MP and IP joints of both hands. The left lower extremity, the thigh compartment is supple. She has pain with log rolling tenderness over the greater trochanter. The patient has pain with any attempt at hip flexion passively or actively. The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism. She has 2 to 3+ bilateral pitting edema pretibially and pedally. The patient has a weak motor response to the left lower extremity. She has a 1+ dorsalis pedis pulse. Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:, Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm. There is no evidence of dislocation. There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture. There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine. There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets. Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62. Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1. This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip. The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2. Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:, I have discussed this case with the emergency room physician as well as the patient. Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation. Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure. She will need cardiology clearance, which would include an echo in advance of the procedure. I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter. She presently understands and agrees with the plan.

The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.

Emergency Room Reports

Fall - ER Visit

she, the, left, is, and

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. The patient states that she was on the ladder on Saturday and she stepped down after the ladder. Felt some pain in her left hip. Subsequently fell injuring her left shoulder. It's unclear how long she was on the floor. She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture. Orthopedics was consulted. Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only. She presently is complaining of pain to the left shoulder. She states she also has pain to the hip with motion of the leg. She denies any numbness or paresthesias. She states prior to this, she was relatively active within her home. She does care for her daughter who has a mess. The patient denies any other injuries. Denies back pain.,PREVIOUS MEDICAL HISTORY:, Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:, Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1. PENICILLIN.,2. SULFA.,3. ACE INHIBITOR.,PRESENT MEDICATIONS,1. Lipitor 20 mg q.d.,2. Metoprolol 25 mg b.i.d.,3. Plavix 75 mg once a day.,4. Aspirin 325 mg.,5. Combivent Aerosol two puffs twice a day.,6. Protonix 40 mg q.d.,7. Fosamax 70 mg weekly.,8. Multivitamins including calcium and vitamin D.,9. Hydrocortisone.,10. Nitroglycerin.,11. Citalopram 20 mg q.d.,SOCIAL HISTORY:, She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:, Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extremities for the last several weeks. She denies endocrinopathies. Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL: The patient is alert and responsive.,EXTREMITIES: The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment. She is diffusely tender over the proximal humerus. She is unable to actively elevate her arm due to pain. The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse. She does have chronic degenerative change to the MP and IP joints of both hands. The left lower extremity, the thigh compartment is supple. She has pain with log rolling tenderness over the greater trochanter. The patient has pain with any attempt at hip flexion passively or actively. The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism. She has 2 to 3+ bilateral pitting edema pretibially and pedally. The patient has a weak motor response to the left lower extremity. She has a 1+ dorsalis pedis pulse. Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:, Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm. There is no evidence of dislocation. There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture. There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine. There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets. Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62. Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1. This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip. The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2. Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:, I have discussed this case with the emergency room physician as well as the patient. Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation. Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure. She will need cardiology clearance, which would include an echo in advance of the procedure. I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter. She presently understands and agrees with the plan. [/TRANSCRIPTION] [TASK_OUTPUT] Emergency Room Reports [/TASK_OUTPUT] [DESCRIPTION] The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. [/DESCRIPTION] </s>

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PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:, Left patellar chondromalacia with tight lateral structures.,PROCEDURE:, Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: ,47 minutes.,MEDICATION: ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referred to physical therapy for patellar tracking exercises. She was also given a brace. The patient reported increasing pain with physical therapy and mother strongly desired other treatment. It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. Risk and benefits of surgery were discussed. Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A nonsterile tourniquet was placed on the upper aspect of left thigh. The extremity was then prepped and draped in the standard surgical fashion. A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. Incisions were then made. Camera was initially inserted into the lateral joint line. Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation. The patient did have congruent articulation about 30 degrees of knee flexion. Visualization of the medial joint line revealed no loose bodies. There was a small plica. Visualization of the medial joint line revealed no significant chondromalacia. Menisci was probed and tested with no signs of tears and instability. ACL was noted to be intact. The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology. Lateral gutter also demonstrated no loose bodies or plica. The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles. The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed. The patient had significant improvement in anteromedial translation from 25% to 50%. At the end of the case, all instruments were removed. The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine. Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case. The portals were then closed using 4-0 Monocryl. The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s. The kneecap was translated medially under pressure and a bias placed. The tourniquet was released at 47 minutes. The patient was then placed in the knee immobilizer. The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer. She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening. Intraoperative findings were relayed to the mother. All questions were answered.

Left knee arthroscopy with lateral capsular release.

Surgery

Knee Arthroscopy

surgery, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee,

the, was, and, of, patient

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:, Left patellar chondromalacia with tight lateral structures.,PROCEDURE:, Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: ,47 minutes.,MEDICATION: ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referred to physical therapy for patellar tracking exercises. She was also given a brace. The patient reported increasing pain with physical therapy and mother strongly desired other treatment. It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. Risk and benefits of surgery were discussed. Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A nonsterile tourniquet was placed on the upper aspect of left thigh. The extremity was then prepped and draped in the standard surgical fashion. A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. Incisions were then made. Camera was initially inserted into the lateral joint line. Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation. The patient did have congruent articulation about 30 degrees of knee flexion. Visualization of the medial joint line revealed no loose bodies. There was a small plica. Visualization of the medial joint line revealed no significant chondromalacia. Menisci was probed and tested with no signs of tears and instability. ACL was noted to be intact. The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology. Lateral gutter also demonstrated no loose bodies or plica. The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles. The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed. The patient had significant improvement in anteromedial translation from 25% to 50%. At the end of the case, all instruments were removed. The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine. Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case. The portals were then closed using 4-0 Monocryl. The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s. The kneecap was translated medially under pressure and a bias placed. The tourniquet was released at 47 minutes. The patient was then placed in the knee immobilizer. The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer. She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening. Intraoperative findings were relayed to the mother. All questions were answered. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Left knee arthroscopy with lateral capsular release. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.63

PREOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS: ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy.

True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

Surgery

True Cut Needle Biopsy - Breast

surgery, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast,

the, of, left, was, procedure

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS: ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy. [/TRANSCRIPTION] [TASK_OUTPUT] 0.63 [/TASK_OUTPUT] [DESCRIPTION] True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, was, and, of, to

PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1. Closed type-III supracondylar fracture, left distal humerus.,2. Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital. A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS: ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing. He apparently had not had previous problems with his left arm. He was seen in the Emergency with a grossly deformed left elbow. His parents' were both present preoperatively. His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region. Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible. He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department. Closed reduction was accomplished in a sequential manner. Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly. Then a slow longitudinal traction was carried out. The elbow was hyperflexed. Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve. The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally. Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital. He had scrubbed in to the case to follow up on the loss of the radial artery distally. This was not present palpatory, but also by Doppler. A weak ulnar artery pulse was present via Doppler. Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______. A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery. Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this. I then came back in and then we proceeded. He was prepped and draped in the usual sterile manner. Please see Dr. X's report for the discussion of the exploration and release of the brachial artery. There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally. Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure. Steri-Strips were placed. The patient's arm was placed in just a slight degree of flexion with a neutral position. He was splinted posteriorly. Adaptic and fluffs have been placed around the patient's pin sites. K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above. There is concern for growth plate disturbance. He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning. There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function.

Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.

Surgery

Closed Reduction Percutaneous Pinning

surgery, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow,

the, was, and, of, to

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1. Closed type-III supracondylar fracture, left distal humerus.,2. Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital. A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS: ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing. He apparently had not had previous problems with his left arm. He was seen in the Emergency with a grossly deformed left elbow. His parents' were both present preoperatively. His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region. Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible. He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department. Closed reduction was accomplished in a sequential manner. Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly. Then a slow longitudinal traction was carried out. The elbow was hyperflexed. Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve. The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally. Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital. He had scrubbed in to the case to follow up on the loss of the radial artery distally. This was not present palpatory, but also by Doppler. A weak ulnar artery pulse was present via Doppler. Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______. A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery. Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this. I then came back in and then we proceeded. He was prepped and draped in the usual sterile manner. Please see Dr. X's report for the discussion of the exploration and release of the brachial artery. There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally. Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure. Steri-Strips were placed. The patient's arm was placed in just a slight degree of flexion with a neutral position. He was splinted posteriorly. Adaptic and fluffs have been placed around the patient's pin sites. K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above. There is concern for growth plate disturbance. He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning. There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function. [/TRANSCRIPTION] [TASK_OUTPUT] the, was, and, of, to [/TASK_OUTPUT] [DESCRIPTION] Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow. [/DESCRIPTION] </s>

Summarize this medical transcription

Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.

PREOPERATIVE DIAGNOSES:,1. Entropion, left upper lid.,2. Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room and prepped and draped in the usual fashion. The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness. The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place. An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised. Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade. Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery. An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure. Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied. No patch was applied to the left eye. The patient tolerated the procedure well and was sent to recovery room in good condition.

Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.

Surgery

Blepharon & Entropion Repair

surgery, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane

the, was, and, lower, of

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Entropion, left upper lid.,2. Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room and prepped and draped in the usual fashion. The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness. The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place. An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised. Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade. Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery. An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure. Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied. No patch was applied to the left eye. The patient tolerated the procedure well and was sent to recovery room in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft. [/TASK_OUTPUT] [DESCRIPTION] Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Bunionectomy & Osteotomy

PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot. The patient has a history of gradual onset of a painful bunion over the past several years. She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion. The foot was elevated off the table. Esmarch bandages were used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and the sterile stockinet was reflected. A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate. Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion. A #10 blade was used to make a 4 cm dorsolinear incision. A #15 blade was used to deepen the incision through the subcutaneous layer. All superficial subcutaneous vessels were ligated with electrocautery. Next, a linear capsular incision was made down the bone with a #15 blade. The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound. A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head. The medial plantar aspect of the metatarsal head had some erosive changes and eburnation. Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it. A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion. Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head. Nice correction was achieved and excellent bone to bone contact was achieved. The bone stock was slightly decreased, but adequate. Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment. A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique. Excellent rigid fixation was achieved. 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. The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge. A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy. A #15 drill blade was used to drill two converging holes on the medial aspect of the bone. A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone. The monofilament wire was twisted down and tapped into the distal drill hole. The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved. Next, reciprocating rasps were used to smooth all bony surfaces. Copious amounts of sterile saline was used to flush the joint. Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer. Next, #4-0 Vicryl was used to close the subcutaneous layer. #5-0 Vicryl was used to the close the subcuticular layer in a running fashion. Next, 1 cc of dexamethasone phosphate was then instilled in the joint. The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She is to be partial weightbearing with crutches. She is to follow with Dr. X. She was given emergency contact numbers and instructions to call if problems arise. She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d. 500 mg. She was discharged in stable condition.

Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.

Podiatry

Bunionectomy & Osteotomy

podiatry, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal

the, was, to, used, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot. The patient has a history of gradual onset of a painful bunion over the past several years. She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion. The foot was elevated off the table. Esmarch bandages were used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and the sterile stockinet was reflected. A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate. Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion. A #10 blade was used to make a 4 cm dorsolinear incision. A #15 blade was used to deepen the incision through the subcutaneous layer. All superficial subcutaneous vessels were ligated with electrocautery. Next, a linear capsular incision was made down the bone with a #15 blade. The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound. A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head. The medial plantar aspect of the metatarsal head had some erosive changes and eburnation. Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it. A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion. Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head. Nice correction was achieved and excellent bone to bone contact was achieved. The bone stock was slightly decreased, but adequate. Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment. A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique. Excellent rigid fixation was achieved. 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. The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge. A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy. A #15 drill blade was used to drill two converging holes on the medial aspect of the bone. A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone. The monofilament wire was twisted down and tapped into the distal drill hole. The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved. Next, reciprocating rasps were used to smooth all bony surfaces. Copious amounts of sterile saline was used to flush the joint. Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer. Next, #4-0 Vicryl was used to close the subcutaneous layer. #5-0 Vicryl was used to the close the subcuticular layer in a running fashion. Next, 1 cc of dexamethasone phosphate was then instilled in the joint. The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She is to be partial weightbearing with crutches. She is to follow with Dr. X. She was given emergency contact numbers and instructions to call if problems arise. She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d. 500 mg. She was discharged in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Bunionectomy & Osteotomy [/TASK_OUTPUT] [DESCRIPTION] Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Neurosurgery

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.

Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.

Neurosurgery

Thoracic Discectomy

neurosurgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,

we, the, and, then, to

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home. [/TRANSCRIPTION] [TASK_OUTPUT] Neurosurgery [/TASK_OUTPUT] [DESCRIPTION] Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,

PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,BLOOD LOSS: ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:, None.,INDICATION FOR OPERATION: ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. Risks and benefits of procedure were discussed in detail with the patient and her husband. All questions were answered, and consent was obtained. The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1. There was a comminuted distal tibia fracture with a fibular shaft fracture. Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. As the reduction was stable with buddy taping, no pinning was performed.,3. Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL: ,The patient was identified in the preoperative holding area. The left leg was identified and marked at the surgical site of the patient. She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. She received Ancef for antibiotic prophylaxis. A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. At this point, the pins were cut short and capped to protect the sharp ends. The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. Please note there was no break in sterile technique throughout the case.,PLAN: ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. She will maintain her buddy taping in regards to her great toe fracture.

External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.

Surgery

Pilon Fracture External Fixation

surgery, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,

the, and, was, of, in

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,BLOOD LOSS: ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:, None.,INDICATION FOR OPERATION: ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. Risks and benefits of procedure were discussed in detail with the patient and her husband. All questions were answered, and consent was obtained. The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1. There was a comminuted distal tibia fracture with a fibular shaft fracture. Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. As the reduction was stable with buddy taping, no pinning was performed.,3. Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL: ,The patient was identified in the preoperative holding area. The left leg was identified and marked at the surgical site of the patient. She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. She received Ancef for antibiotic prophylaxis. A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. At this point, the pins were cut short and capped to protect the sharp ends. The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. Please note there was no break in sterile technique throughout the case.,PLAN: ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. She will maintain her buddy taping in regards to her great toe fracture. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation, [/TASK_OUTPUT] [DESCRIPTION] External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Gen Med Consult - 49

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. The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1. Diabetes mellitus type 2.,2. Diabetic nephropathy.,3. Chronic kidney disease, stage 4.,4. Hypertension.,5. Hypercholesterolemia and hyperlipidemia.,6. Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:, Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:, NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General: The patient is alert and oriented, in no acute distress.,Vital Signs: Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. The patient's weight is 105.6 kg.,Head: Normocephalic.,Neck: Supple. No JVD. No adenopathy.,Chest: Symmetric. No retractions.,Lungs: Clear.,Heart: RRR with no murmur.,Abdomen: Obese, soft, and nontender. No rebound. No guarding.,Extremity: She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date. The patient's white cell is 12.7, hematocrit 26.1. The patient has 90% segs and 0% bands. Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1. Urinary tract infection.,2. Acute gouty attack.,3. Diabetes mellitus with diabetic nephropathy.,4. Hypertension.,5. Hypercholesterolemia.,6. Peripheral vascular disease, status post recent PTA in the right side.,7. Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment. We will add allopurinol 50 mg daily. This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.

A 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.

Consult - History and Phy.

Gen Med Consult - 49

and, the, mg, disease, is

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] 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. The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1. Diabetes mellitus type 2.,2. Diabetic nephropathy.,3. Chronic kidney disease, stage 4.,4. Hypertension.,5. Hypercholesterolemia and hyperlipidemia.,6. Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:, Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:, NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General: The patient is alert and oriented, in no acute distress.,Vital Signs: Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. The patient's weight is 105.6 kg.,Head: Normocephalic.,Neck: Supple. No JVD. No adenopathy.,Chest: Symmetric. No retractions.,Lungs: Clear.,Heart: RRR with no murmur.,Abdomen: Obese, soft, and nontender. No rebound. No guarding.,Extremity: She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date. The patient's white cell is 12.7, hematocrit 26.1. The patient has 90% segs and 0% bands. Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1. Urinary tract infection.,2. Acute gouty attack.,3. Diabetes mellitus with diabetic nephropathy.,4. Hypertension.,5. Hypercholesterolemia.,6. Peripheral vascular disease, status post recent PTA in the right side.,7. Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment. We will add allopurinol 50 mg daily. This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results. [/TRANSCRIPTION] [TASK_OUTPUT] Gen Med Consult - 49 [/TASK_OUTPUT] [DESCRIPTION] A 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. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

HISTORY OF PRESENT ILLNESS:, A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.,ALLERGIES:, She is allergic to Sulfa.,CURRENT MEDICATIONS:, Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.,Skin: Without rash.,Eyes: PERRLA. Conjunctivae are clear.,Neck: Supple with adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,ASSESSMENT:,1. Postsurgical menopause.,2. Mood swings.,PLAN:, I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well.

Complaint of mood swings and tearfulness.

General Medicine

Gen Med Consult - 15

general medicine, tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,

she, her, is, the, any

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS:, A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.,ALLERGIES:, She is allergic to Sulfa.,CURRENT MEDICATIONS:, Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.,Skin: Without rash.,Eyes: PERRLA. Conjunctivae are clear.,Neck: Supple with adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,ASSESSMENT:,1. Postsurgical menopause.,2. Mood swings.,PLAN:, I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Complaint of mood swings and tearfulness. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Neurologic Consultation - 1

SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed. There are no changes, otherwise.,REVIEW OF SYSTEMS:, Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented. Extraocular movements are full. The face is symmetric. The uvula is midline. Speech has normal prosody. Today there is much less guarding of the left shoulder. In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full. The gait is narrow based and noncircumductive. Rapid alternating movements are slightly off bilaterally. The gait does not have significant slapping characteristics. Sensory examination is largely unremarkable. Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same. We discussed the issue of adherence to Copaxone. In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm. His wife continues to inject him. He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.

Neurologic consultation and follow-up.

Consult - History and Phy.

Neurologic Consultation - 1

consult - history and phy., neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,

the, are, is, of, to

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed. There are no changes, otherwise.,REVIEW OF SYSTEMS:, Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented. Extraocular movements are full. The face is symmetric. The uvula is midline. Speech has normal prosody. Today there is much less guarding of the left shoulder. In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full. The gait is narrow based and noncircumductive. Rapid alternating movements are slightly off bilaterally. The gait does not have significant slapping characteristics. Sensory examination is largely unremarkable. Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same. We discussed the issue of adherence to Copaxone. In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm. His wife continues to inject him. He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling. [/TRANSCRIPTION] [TASK_OUTPUT] Neurologic Consultation - 1 [/TASK_OUTPUT] [DESCRIPTION] Neurologic consultation and follow-up. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, , Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30): Within normal limits.,CXR (12/8): Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:, The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.

Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.

General Medicine

Gen Med Consult - 24

he, his, the, and, of

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, , Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30): Within normal limits.,CXR (12/8): Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:, The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. [/DESCRIPTION] </s>

Summarize this medical transcription

Common CT Head template.

TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are within normal limits. ,IMPRESSION: , No acute abnormalities.

Common CT Head template.

Neurology

CT Head

neurology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE

the, are, normal, and, no

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are within normal limits. ,IMPRESSION: , No acute abnormalities. [/TRANSCRIPTION] [TASK_OUTPUT] Common CT Head template. [/TASK_OUTPUT] [DESCRIPTION] Common CT Head template. [/DESCRIPTION] </s>

Summarize this medical transcription

A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.

A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.

Pediatrics - Neonatal

Congestion & Cough - 5-month-Old

she, her, was, and, history

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed. [/TRANSCRIPTION] [TASK_OUTPUT] A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. [/TASK_OUTPUT] [DESCRIPTION] A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.50

As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having "overactive bladder", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could "barely walk". She felt as if her balance is impaired and she felt as if she were "walking on stilts". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to "look better". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished female in no acute distress.,Head: Normocephalic, without evidence of trauma or bruits.,Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy.,Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements.

A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.

Neurology

Comprehensive Neurological Evaluation

she, and, the, her, of

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having "overactive bladder", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could "barely walk". She felt as if her balance is impaired and she felt as if she were "walking on stilts". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to "look better". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished female in no acute distress.,Head: Normocephalic, without evidence of trauma or bruits.,Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy.,Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements. [/TRANSCRIPTION] [TASK_OUTPUT] 0.50 [/TASK_OUTPUT] [DESCRIPTION] A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room.

Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.

Urology

Hydrocelectomy

urology, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,

the, was, then, and, placed

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Facet Arthrogram & Injection

PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view. A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left. Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side. This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen. Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected. Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint. The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. The 22-gauge needle was then removed. Pressure was place over the puncture site for approximately one minute. This exact same procedure was then repeated along the left-sided facets at L45, and L5S1. This exact same procedure was then repeated on the right side. At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1. Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this. Dye spread into each joint space is visualized. No venous or arterial run-off is noted. No epidural run-off is noted. The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.

Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain.

Surgery

Facet Arthrogram & Injection

surgery, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,

the, was, of, and, then

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view. A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left. Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side. This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen. Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected. Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint. The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. The 22-gauge needle was then removed. Pressure was place over the puncture site for approximately one minute. This exact same procedure was then repeated along the left-sided facets at L45, and L5S1. This exact same procedure was then repeated on the right side. At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1. Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this. Dye spread into each joint space is visualized. No venous or arterial run-off is noted. No epidural run-off is noted. The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis. [/TRANSCRIPTION] [TASK_OUTPUT] Facet Arthrogram & Injection [/TASK_OUTPUT] [DESCRIPTION] Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

General Medicine

CONSULT REQUEST FOR:, Medical management.,The patient has been in special procedures now for over 2 hours and I am unable to examine.,HISTORY OF PRESENT ILLNESS:, Obtained from Dr. A on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. She was unfortunately outside of the window for emergent treatment and had a negative CT scan of the head. Was started on protocol medication and that is similar to TPA, which is an investigational study.,During the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. Her heart rate was 130. She was brought down with Cardizem. She received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as TPA has no obvious known association with this.,At that time the patient became comatose and required emergent intubation and paralyzation. Her diastolic at that time rose up to 190, likely the result of the acute second stroke. She is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. Dr. A has updated the family to her extremely guarded and critical prognosis.,At present, it is not known yet, we do not have the STAT echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. Echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,REVIEW OF SYSTEMS:, Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.,PAST MEDICAL HISTORY:, GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three years.,PAST SURGICAL HISTORY:, Cholecystectomy, TAH 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,ALLERGIES:, MORPHINE, SULFAS (RASH), PROZAC.,MEDICATIONS AT HOME: Lanoxin 0.25 daily; Inderal LA 80 daily; MOBIC 7.5 daily; Robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen PRN; Darvocet-N 100 PRN.,SOCIAL HISTORY:, She does not drink or smoke. Lives in Fayetteville, Tennessee.,FAMILY HISTORY:, Mother died of cancer, unknown type. Dad died of an MI.,VACCINATION STATUS: Unknown.,PHYSICAL EXAMINATION:,VITAL SIGNS: On arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,GENERAL: She was apparently alert and able to give history on arrival. Currently do not have any available vital signs or physical exam, as I cannot get to the patient.,LABORATORY: ,Reviewed and are remarkable for white count of 13 with 76 neutrophils. BMP is normal, except for a blood sugar of 157, hemoglobin A1c is pending. TSH 2.1, cholesterol 165, Digoxin 1.24, CPK 57. ABG 7.47/32/459 on 100%. Magnesium 1.5. ESR 9, coags normal.,EKG is pending my review.,Chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,Chest x-ray, shoulder films and CT scan of the head: I have reviewed. Chest x-ray has good ET tube placement. She has mild cardiomegaly. Some mild interstitial opacities consistent with OGD and minimal amount of atherosclerosis of the aorta.,CT scan of the head: I do not see any active bleeding.,X-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,ASSESSMENT/PLAN/PROBLEMS:,1. Large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. Obviously she is in critical condition and stable with multiple strokes. One must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. We need STAT records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. I have ordered a STAT echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a PFO we may be able to better prognosticate at this point. Obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by Dr. A and interventional radiology.,2. Hypertension/atrial fibrillation: This will be a difficult management and the fact that she has been on a beta-blocker for Parkinson's, she may have withdrawal to the beta-blockers as we remove this. Given her atrial fibrillation, I do agree the safest agent right now is to use a Cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. Also, would use it to control the atrial fibrillation. We would, however, be very cautious not to put her in heart block with the Digoxin and the beta-blocker on board. Weighing all risks and benefits, I think that given the fact that she has a beta-blocker on board and Digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. If, however, we run into trouble with this, I would prefer to switch her to Brevibloc or an Esmolol drip and see how she does, as she may withdraw from the beta-blocker. I will be watching this closely and managing the hypertension as I see fit at the moment, based on all factors. Will also ask cardiology if she has one that sees her here, to help guide this. Her Digoxin level is appropriate, as well as a TSH. I do not feel that we need to work this up further, other than the STAT echo and ultrasound of the leg.,3. Respiratory failure requiring ventilator: I have discussed this with Dr. Devlin, we do not feel the need to hyperventilate her at present. We will keep her comfortable on the breathing machine and try to keep her pH in a normal range, around 7.4, and her CO2 in the 30 to 40 range. If she has brain swelling, we will need to hyperventilate her to a pCO2 of 30 and a pH of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. Optimize electrolytes as you can.,5. Deep vein thrombosis prophylaxis for now, with thigh-high TED hose, possibly SCDs, although I do not have experience with the vampire/venom to know if we need to worry about DIC which the SCDs may worsen. Will follow daily CBCs for that.,6. Nutrition: Will go ahead and start a low dose of tube feeds and hope that she does survive.,I will defer all updates to the family for the next 24 to 48 hours to Dr. Devlin's expertise, given her unknown and fluctuating neurologic prognosis.,Thank you so much for allowing us to participate in her care. We will be happy to do all medication treatment until the point that I feel that I would need any help from critical care. I believe that we will be able to manage her fully at this point, for simplicity sake.

Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management

General Medicine

Medical Management Consult Request

the, she, to, her, and

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] CONSULT REQUEST FOR:, Medical management.,The patient has been in special procedures now for over 2 hours and I am unable to examine.,HISTORY OF PRESENT ILLNESS:, Obtained from Dr. A on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. She was unfortunately outside of the window for emergent treatment and had a negative CT scan of the head. Was started on protocol medication and that is similar to TPA, which is an investigational study.,During the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. Her heart rate was 130. She was brought down with Cardizem. She received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as TPA has no obvious known association with this.,At that time the patient became comatose and required emergent intubation and paralyzation. Her diastolic at that time rose up to 190, likely the result of the acute second stroke. She is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. Dr. A has updated the family to her extremely guarded and critical prognosis.,At present, it is not known yet, we do not have the STAT echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. Echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,REVIEW OF SYSTEMS:, Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.,PAST MEDICAL HISTORY:, GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three years.,PAST SURGICAL HISTORY:, Cholecystectomy, TAH 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,ALLERGIES:, MORPHINE, SULFAS (RASH), PROZAC.,MEDICATIONS AT HOME: Lanoxin 0.25 daily; Inderal LA 80 daily; MOBIC 7.5 daily; Robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen PRN; Darvocet-N 100 PRN.,SOCIAL HISTORY:, She does not drink or smoke. Lives in Fayetteville, Tennessee.,FAMILY HISTORY:, Mother died of cancer, unknown type. Dad died of an MI.,VACCINATION STATUS: Unknown.,PHYSICAL EXAMINATION:,VITAL SIGNS: On arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,GENERAL: She was apparently alert and able to give history on arrival. Currently do not have any available vital signs or physical exam, as I cannot get to the patient.,LABORATORY: ,Reviewed and are remarkable for white count of 13 with 76 neutrophils. BMP is normal, except for a blood sugar of 157, hemoglobin A1c is pending. TSH 2.1, cholesterol 165, Digoxin 1.24, CPK 57. ABG 7.47/32/459 on 100%. Magnesium 1.5. ESR 9, coags normal.,EKG is pending my review.,Chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,Chest x-ray, shoulder films and CT scan of the head: I have reviewed. Chest x-ray has good ET tube placement. She has mild cardiomegaly. Some mild interstitial opacities consistent with OGD and minimal amount of atherosclerosis of the aorta.,CT scan of the head: I do not see any active bleeding.,X-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,ASSESSMENT/PLAN/PROBLEMS:,1. Large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. Obviously she is in critical condition and stable with multiple strokes. One must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. We need STAT records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. I have ordered a STAT echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a PFO we may be able to better prognosticate at this point. Obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by Dr. A and interventional radiology.,2. Hypertension/atrial fibrillation: This will be a difficult management and the fact that she has been on a beta-blocker for Parkinson's, she may have withdrawal to the beta-blockers as we remove this. Given her atrial fibrillation, I do agree the safest agent right now is to use a Cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. Also, would use it to control the atrial fibrillation. We would, however, be very cautious not to put her in heart block with the Digoxin and the beta-blocker on board. Weighing all risks and benefits, I think that given the fact that she has a beta-blocker on board and Digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. If, however, we run into trouble with this, I would prefer to switch her to Brevibloc or an Esmolol drip and see how she does, as she may withdraw from the beta-blocker. I will be watching this closely and managing the hypertension as I see fit at the moment, based on all factors. Will also ask cardiology if she has one that sees her here, to help guide this. Her Digoxin level is appropriate, as well as a TSH. I do not feel that we need to work this up further, other than the STAT echo and ultrasound of the leg.,3. Respiratory failure requiring ventilator: I have discussed this with Dr. Devlin, we do not feel the need to hyperventilate her at present. We will keep her comfortable on the breathing machine and try to keep her pH in a normal range, around 7.4, and her CO2 in the 30 to 40 range. If she has brain swelling, we will need to hyperventilate her to a pCO2 of 30 and a pH of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. Optimize electrolytes as you can.,5. Deep vein thrombosis prophylaxis for now, with thigh-high TED hose, possibly SCDs, although I do not have experience with the vampire/venom to know if we need to worry about DIC which the SCDs may worsen. Will follow daily CBCs for that.,6. Nutrition: Will go ahead and start a low dose of tube feeds and hope that she does survive.,I will defer all updates to the family for the next 24 to 48 hours to Dr. Devlin's expertise, given her unknown and fluctuating neurologic prognosis.,Thank you so much for allowing us to participate in her care. We will be happy to do all medication treatment until the point that I feel that I would need any help from critical care. I believe that we will be able to manage her fully at this point, for simplicity sake. [/TRANSCRIPTION] [TASK_OUTPUT] General Medicine [/TASK_OUTPUT] [DESCRIPTION] Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Letter - Dentistry

XYZ, S.,RE: ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18. This previously root-canaled tooth, now failed, is scheduled for removal. As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant. I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period. If you have any additional suggestions or concerns, please give me a call.,Best regards,,

Letter on evaluation regarding extraction of mandibular left second molar tooth #18.

Dentistry

Letter - Dentistry

dentistry, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth

the, of, this, have, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] XYZ, S.,RE: ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18. This previously root-canaled tooth, now failed, is scheduled for removal. As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant. I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period. If you have any additional suggestions or concerns, please give me a call.,Best regards,, [/TRANSCRIPTION] [TASK_OUTPUT] Letter - Dentistry [/TASK_OUTPUT] [DESCRIPTION] Letter on evaluation regarding extraction of mandibular left second molar tooth #18. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Ophthalmology

PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:, Radioactive plaque macular edema.,TITLE OF OPERATION:, Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure. Then a retrobulbar injection of 2% Xylocaine was performed. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. Next, the plaque was identified and the two scleral sutures were removed. The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture. The fundus was inspected with direct ophthalmoscopy. An eye patch was applied following Neosporin solution irrigation. The patient was sent to the recovery room in good condition. A lateral canthotomy had been done.

Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.

Ophthalmology

Radioactive Plaque - Removal

ophthalmology, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque

the, was, of, and, diagnosis

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:, Radioactive plaque macular edema.,TITLE OF OPERATION:, Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure. Then a retrobulbar injection of 2% Xylocaine was performed. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. Next, the plaque was identified and the two scleral sutures were removed. The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture. The fundus was inspected with direct ophthalmoscopy. An eye patch was applied following Neosporin solution irrigation. The patient was sent to the recovery room in good condition. A lateral canthotomy had been done. [/TRANSCRIPTION] [TASK_OUTPUT] Ophthalmology [/TASK_OUTPUT] [DESCRIPTION] Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Laparoscopic Appendectomy - 2

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed. No leakage of enteral contents was noted. All trocars were removed under direct visualization. The umbilical fascia was closed with interrupted 0 Vicryl sutures. The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's. The patient was extubated and taken to the recovery area in stable condition. The patient tolerated the procedure well.

Appendicitis. Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants.

Surgery

Laparoscopic Appendectomy - 2

surgery, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical

the, was, and, with, procedure

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed. No leakage of enteral contents was noted. All trocars were removed under direct visualization. The umbilical fascia was closed with interrupted 0 Vicryl sutures. The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's. The patient was extubated and taken to the recovery area in stable condition. The patient tolerated the procedure well. [/TRANSCRIPTION] [TASK_OUTPUT] Laparoscopic Appendectomy - 2 [/TASK_OUTPUT] [DESCRIPTION] Appendicitis. Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

LEEP

DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.

LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.

Surgery

LEEP

surgery, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented

the, was, of, and, in

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] LEEP [/TASK_OUTPUT] [DESCRIPTION] LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.

Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.

Surgery

AC Separation Revision & Hardware Removal

surgery, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware

and, was, the, right, taken

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.56

REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen wearing clothes inside out along with other unusual behaviors. In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense. The patient sought treatment from an ophthalmologist. We did not find any abnormality in the Behavior Center in Tyler, Texas. The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses. The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college. She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety. Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006. Sleeping patterns and the amount is unknown. Appetite is okay.,PAST PSYCHIATRIC HISTORY:, The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor. She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work. No current medications. Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY: ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother. Both, the mother's father and father's mother had "nervous breakdowns" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II: Deferred.,AXIS III: Deferred.,AXIS IV: Deferred.,AXIS V: 1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history. There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate. The patient presented with headaches, vision forms, and disorientation in June 2006. She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests. Thank you very much for the consultation.

Psychiatric Consultation of patient with dementia.

Psychiatry / Psychology

Psych Consult - Dementia

psychiatry / psychology, reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultation, headaches,

the, patient, and, of, to

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen wearing clothes inside out along with other unusual behaviors. In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense. The patient sought treatment from an ophthalmologist. We did not find any abnormality in the Behavior Center in Tyler, Texas. The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses. The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college. She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety. Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006. Sleeping patterns and the amount is unknown. Appetite is okay.,PAST PSYCHIATRIC HISTORY:, The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor. She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work. No current medications. Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY: ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother. Both, the mother's father and father's mother had "nervous breakdowns" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II: Deferred.,AXIS III: Deferred.,AXIS IV: Deferred.,AXIS V: 1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history. There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate. The patient presented with headaches, vision forms, and disorientation in June 2006. She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests. Thank you very much for the consultation. [/TRANSCRIPTION] [TASK_OUTPUT] 0.56 [/TASK_OUTPUT] [DESCRIPTION] Psychiatric Consultation of patient with dementia. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,POSTOPERATIVE DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:, A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9. There was normal pelvic anatomy, normal tubes. The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip. The abdomen was prepped and draped in a sterile fashion. A Pfannenstiel incision was made and carried sharply down to the level of fascia. The fascia was incised transversely. The fascia was dissected away from the underlying rectus muscles. With sharp and blunt dissection, rectus muscles were divided in midline. The perineum was entered bluntly. The incision was carried vertically with scissors. Transverse incision was made across the bladder peritoneum. The bladder was dissected away from the underlying lower uterine segment. Bladder retractor was placed to protect the bladder. The lower uterine segment was entered sharply with a scalpel. Incision was carried transversely with bandage scissors. Clear amniotic fluids were encountered. The infant was out of the pelvis and was in oblique vertex presentation. The head was brought down into the incision and delivered easily as were the shoulders and body. The mouth and oropharynx were suctioned vigorously. The cord was clamped and cut. The infant was passed off to the waiting pediatrician in satisfactory condition. Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact. Uterus was explored and found to be empty. Uterus was delivered through the abdominal incision and massaged vigorously. Intravenous Pitocin was administered. T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis. Secondary running locking stitch was placed for extra strength to the wound. At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut. Intervening knuckle was excised and passed off the field. The proximal end of the tubal mucosa was cauterized. Cul-de-sac and gutters were suctioned vigorously. The uterus was returned to its proper anatomic position in the abdomen. The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl. Uterus was expressed of its contents. Patient was brought to the recovery room in satisfactory condition. There were no complications. There was 600 cc of blood loss. All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.

Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at term with previous cesarean section. Desires permanent sterilization. Macrosomia.

Obstetrics / Gynecology

Low-Transverse C-Section & BTL

obstetrics / gynecology, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine,

was, the, and, incision, of

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,POSTOPERATIVE DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:, A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9. There was normal pelvic anatomy, normal tubes. The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip. The abdomen was prepped and draped in a sterile fashion. A Pfannenstiel incision was made and carried sharply down to the level of fascia. The fascia was incised transversely. The fascia was dissected away from the underlying rectus muscles. With sharp and blunt dissection, rectus muscles were divided in midline. The perineum was entered bluntly. The incision was carried vertically with scissors. Transverse incision was made across the bladder peritoneum. The bladder was dissected away from the underlying lower uterine segment. Bladder retractor was placed to protect the bladder. The lower uterine segment was entered sharply with a scalpel. Incision was carried transversely with bandage scissors. Clear amniotic fluids were encountered. The infant was out of the pelvis and was in oblique vertex presentation. The head was brought down into the incision and delivered easily as were the shoulders and body. The mouth and oropharynx were suctioned vigorously. The cord was clamped and cut. The infant was passed off to the waiting pediatrician in satisfactory condition. Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact. Uterus was explored and found to be empty. Uterus was delivered through the abdominal incision and massaged vigorously. Intravenous Pitocin was administered. T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis. Secondary running locking stitch was placed for extra strength to the wound. At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut. Intervening knuckle was excised and passed off the field. The proximal end of the tubal mucosa was cauterized. Cul-de-sac and gutters were suctioned vigorously. The uterus was returned to its proper anatomic position in the abdomen. The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl. Uterus was expressed of its contents. Patient was brought to the recovery room in satisfactory condition. There were no complications. There was 600 cc of blood loss. All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at term with previous cesarean section. Desires permanent sterilization. Macrosomia. [/DESCRIPTION] </s>

Summarize this medical transcription

Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).

CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.

Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).

Radiology

Cerebral Angiogram

the, and, he, of, to

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation. [/TRANSCRIPTION] [TASK_OUTPUT] Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx). [/TASK_OUTPUT] [DESCRIPTION] Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx). [/DESCRIPTION] </s>

Extract key medical terms from this text

she, and, her, is, negative

FAMILY HISTORY:, Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:, She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed. She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:, Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:, In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS: ,HEENT: For headaches and sore throat. Musculoskeletal: She is right handed with joint pain, stiffness, and decreased range of motion. Cardiac: For heart murmur. GI: Negative and noncontributory. Respiratory: Negative and noncontributory. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory. Genital: Negative and noncontributory. She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall. Current weight is 132 pounds, weight one year ago was 126 pounds. BP is 122/68. On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. General, a well-developed and well-nourished female in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth good dentition. Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movement. Cranial nerve VIII, hearing intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. Examination of the low back reveals some mild paralumbar spasms. She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature. She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation. Deep tendon reflexes are 2+ bilateral knees and ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Straight leg raising is negative bilaterally. Strength on manual exam is 5/5 and equal bilateral lower extremity. She is able to ambulate on her toes and her heels without any difficulty. She is able to get up standing on one foot on to the toes. She does have some difficulty getting up on to her heels when standing on one foot. She has trouble with this on the left and right. She complains of increased pain while doing this as well. She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left. Sensation is intact. She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout. At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged. At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear. This could represent a facet synovial cyst. This is lateral to the facet. She does not have x-rays for review. She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1 Do nothing.,2. Conservative therapies.,3. Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays. We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that. After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing. All questions and concerns were addressed. If she should have any further questions, concerns, or complications, she will contact our office immediately. Otherwise, we will see her as scheduled. Case was reviewed and discussed with Dr. L.

Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.

Orthopedic

Lumbar Radiculopathy - Consult

orthopedic, back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia,

she, and, her, is, negative

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] FAMILY HISTORY:, Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:, She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed. She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:, Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:, In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS: ,HEENT: For headaches and sore throat. Musculoskeletal: She is right handed with joint pain, stiffness, and decreased range of motion. Cardiac: For heart murmur. GI: Negative and noncontributory. Respiratory: Negative and noncontributory. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory. Genital: Negative and noncontributory. She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall. Current weight is 132 pounds, weight one year ago was 126 pounds. BP is 122/68. On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. General, a well-developed and well-nourished female in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth good dentition. Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movement. Cranial nerve VIII, hearing intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. Examination of the low back reveals some mild paralumbar spasms. She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature. She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation. Deep tendon reflexes are 2+ bilateral knees and ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Straight leg raising is negative bilaterally. Strength on manual exam is 5/5 and equal bilateral lower extremity. She is able to ambulate on her toes and her heels without any difficulty. She is able to get up standing on one foot on to the toes. She does have some difficulty getting up on to her heels when standing on one foot. She has trouble with this on the left and right. She complains of increased pain while doing this as well. She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left. Sensation is intact. She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout. At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged. At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear. This could represent a facet synovial cyst. This is lateral to the facet. She does not have x-rays for review. She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1 Do nothing.,2. Conservative therapies.,3. Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays. We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that. After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing. All questions and concerns were addressed. If she should have any further questions, concerns, or complications, she will contact our office immediately. Otherwise, we will see her as scheduled. Case was reviewed and discussed with Dr. L. [/TRANSCRIPTION] [TASK_OUTPUT] she, and, her, is, negative [/TASK_OUTPUT] [DESCRIPTION] Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

MRI Brain - Leukoencephalopathy

CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem.

MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.

Radiology

MRI Brain - Leukoencephalopathy

radiology, mri brain, pml, progressive multifocal leukoencephalopathy, polymyositis, visual field loss, leukoencephalopathy, lower extremity, field loss, white matter, visual field, signal, brain, mri,

and, on, the, she, of

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem. [/TRANSCRIPTION] [TASK_OUTPUT] MRI Brain - Leukoencephalopathy [/TASK_OUTPUT] [DESCRIPTION] MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, and, was, area, in

PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.

Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.

Surgery

Cheek-Neck Facelift

surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck,

the, and, was, area, in

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] the, and, was, area, in [/TASK_OUTPUT] [DESCRIPTION] Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

SOAP / Chart / Progress Notes

SUBJECTIVE:, This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a doctor. She is not currently on Project Access, and so she is here to get something for the pain in her foot. I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004. She said she does not have a primary care physician. She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers. She has been in here multiple times for different kinds of pain. This pain she is having is in her foot. She had surgery on it, and she has plates and screws. She said she was suppose to see Dr. XYZ about getting some of the hardware out of it. The appointment was cancelled, and that is why she came here. It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her. She did not injure her foot in any way recently. It is chronically painful. Every time she does very much exercise it hurts more. We have x-rayed it in the past. She has some hardware there. It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars. On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar. They are all old, and the surgery was done over a year ago. She is walking with a very slight limp. There is no redness. No heat. No swelling of the foot or the ankle. It is mildly tender around the medial side of the foot just inferior to the medial malleolus. It is not warm or red.,ASSESSMENT:, Foot pain.,PLAN:, She has been in here before. She seems very pleasant. Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill. After she left, I got to thinking about it and looked into her record. She has been in here multiple times for pain medicine. She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago. We called Dr. XYZ office. Dr. XYZ nurse said that the patient did not have an appointment today. She has an appointment on June 15, 2004, for a postop check. They did not tell her they would not see her today because of insurance, so the patient was lying to me. We will keep that in mind the next time she returns, because she will likely be back. She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.

Patient having foot pain.

SOAP / Chart / Progress Notes

Foot Pain - SOAP

soap / chart / progress notes, soap, foot pain, primary care physician, project access, insurance, foot, project, access, care, appointment

she, her, not, dr, it

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a doctor. She is not currently on Project Access, and so she is here to get something for the pain in her foot. I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004. She said she does not have a primary care physician. She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers. She has been in here multiple times for different kinds of pain. This pain she is having is in her foot. She had surgery on it, and she has plates and screws. She said she was suppose to see Dr. XYZ about getting some of the hardware out of it. The appointment was cancelled, and that is why she came here. It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her. She did not injure her foot in any way recently. It is chronically painful. Every time she does very much exercise it hurts more. We have x-rayed it in the past. She has some hardware there. It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars. On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar. They are all old, and the surgery was done over a year ago. She is walking with a very slight limp. There is no redness. No heat. No swelling of the foot or the ankle. It is mildly tender around the medial side of the foot just inferior to the medial malleolus. It is not warm or red.,ASSESSMENT:, Foot pain.,PLAN:, She has been in here before. She seems very pleasant. Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill. After she left, I got to thinking about it and looked into her record. She has been in here multiple times for pain medicine. She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago. We called Dr. XYZ office. Dr. XYZ nurse said that the patient did not have an appointment today. She has an appointment on June 15, 2004, for a postop check. They did not tell her they would not see her today because of insurance, so the patient was lying to me. We will keep that in mind the next time she returns, because she will likely be back. She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon. [/TRANSCRIPTION] [TASK_OUTPUT] SOAP / Chart / Progress Notes [/TASK_OUTPUT] [DESCRIPTION] Patient having foot pain. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,

PREOPERATIVE DIAGNOSIS:, Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:, 4/4.,DIFFICULTY:, 1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:, A 64-year-old male who has developed alternating hard and soft stools. He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding. There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided. Preoperative physical examination was performed. Informed consent was obtained. The patient was placed in the left lateral decubitus position. Premedications were given slowly by intravenous push. Rectal examination was performed, which was normal. The scope was introduced and passed with minimal difficulty to the cecum. This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice. The scope was slowly withdrawn, the mucosa carefully visualized. It was normal in its entirety until reaching the sigmoid colon. Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding. In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp. A snare was placed on the stalk of the polyp and divided with electrocautery. The polyp was recovered and sent for pathologic examination. Examination of the stalk showed good hemostasis. The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease. A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended. In addition, 2 polyps, one of which is assuredly an adenoma. Patient needs a repeat colonoscopy in 3 years.

Total colonoscopy with biopsy and snare polypectomy.

Surgery

Colonoscopy & Polypectomy - 3

surgery, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,

the, was, and, of, examination

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:, 4/4.,DIFFICULTY:, 1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:, A 64-year-old male who has developed alternating hard and soft stools. He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding. There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided. Preoperative physical examination was performed. Informed consent was obtained. The patient was placed in the left lateral decubitus position. Premedications were given slowly by intravenous push. Rectal examination was performed, which was normal. The scope was introduced and passed with minimal difficulty to the cecum. This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice. The scope was slowly withdrawn, the mucosa carefully visualized. It was normal in its entirety until reaching the sigmoid colon. Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding. In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp. A snare was placed on the stalk of the polyp and divided with electrocautery. The polyp was recovered and sent for pathologic examination. Examination of the stalk showed good hemostasis. The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease. A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended. In addition, 2 polyps, one of which is assuredly an adenoma. Patient needs a repeat colonoscopy in 3 years. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid, [/TASK_OUTPUT] [DESCRIPTION] Total colonoscopy with biopsy and snare polypectomy. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:, The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes. He had required ventilator assistance and was transported to the ICU setting. Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained. The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube. The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker. The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution. The patient was prepped and draped in usual fashion. The surgeons were gowned and gloved. A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage. Blunt dissection was then carried down until the fascia overlying the strap muscles were identified. At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery. Once the strap muscles have been identified, palpation was performed to identify any arterial aberration. A high-riding innominate was not identified. At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized. Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery. Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion. This cleared a significant portion of the trachea. The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery. Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea. The second tracheal ring was identified. The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based. At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff. The airway was entered and inferior to the base, window was created. The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified. At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen. The balloon was inflated and the ventilator was attached. He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist. Now, all surgical retractors were removed. The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture. The tube was further secured around the patient's neck with IV tubing. Finally, a drain sponge was placed. At this point, procedure was felt to be complete. The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.

Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.

Endocrinology

Tracheostomy & Thyroid Isthmusectomy

endocrinology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy

the, was, to, and, then

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:, The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes. He had required ventilator assistance and was transported to the ICU setting. Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained. The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube. The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker. The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution. The patient was prepped and draped in usual fashion. The surgeons were gowned and gloved. A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage. Blunt dissection was then carried down until the fascia overlying the strap muscles were identified. At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery. Once the strap muscles have been identified, palpation was performed to identify any arterial aberration. A high-riding innominate was not identified. At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized. Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery. Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion. This cleared a significant portion of the trachea. The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery. Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea. The second tracheal ring was identified. The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based. At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff. The airway was entered and inferior to the base, window was created. The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified. At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen. The balloon was inflated and the ventilator was attached. He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist. Now, all surgical retractors were removed. The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture. The tube was further secured around the patient's neck with IV tubing. Finally, a drain sponge was placed. At this point, procedure was felt to be complete. The patient was returned to the ICU setting in stable condition where a chest x-ray is pending. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.

The patient with atypical type right arm discomfort and neck discomfort.

Surgery

Cardiac Catheterization - 2

surgery, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian,

right, the, was, artery, of

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] The patient with atypical type right arm discomfort and neck discomfort. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, of, left, was, procedure

PREOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS: ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy.

True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

Surgery

True Cut Needle Biopsy - Breast

surgery, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast,

the, of, left, was, procedure

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS: ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy. [/TRANSCRIPTION] [TASK_OUTPUT] the, of, left, was, procedure [/TASK_OUTPUT] [DESCRIPTION] True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Ortho - Letter - 2

XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ 07018,Re:

Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.

Letters

Ortho - Letter - 2

letters, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger,

10, after, all, also, an

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ 07018,Re: [/TRANSCRIPTION] [TASK_OUTPUT] Ortho - Letter - 2 [/TASK_OUTPUT] [DESCRIPTION] Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms. [/DESCRIPTION] </s>

Extract key medical terms from this text

artery, the, left, was, to

PREOPERATIVE DIAGNOSES,1. Dyspnea on exertion with abnormal stress echocardiography.,2. Frequent PVCs.,3. Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2. Frequent PVCs.,3. Metabolic syndrome.,PROCEDURES,1. Left heart catheterization with left ventriculography.,2. Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.,Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.,2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.,3. Significant coronary artery disease.,4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN: ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker.

Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 6

cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,

artery, the, left, was, to

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES,1. Dyspnea on exertion with abnormal stress echocardiography.,2. Frequent PVCs.,3. Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2. Frequent PVCs.,3. Metabolic syndrome.,PROCEDURES,1. Left heart catheterization with left ventriculography.,2. Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.,Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.,2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.,3. Significant coronary artery disease.,4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN: ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker. [/TRANSCRIPTION] [TASK_OUTPUT] artery, the, left, was, to [/TASK_OUTPUT] [DESCRIPTION] Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome. [/DESCRIPTION] </s>

Extract key medical terms from this text

10, after, all, also, an

Vaginal Hysterectomy. A weighted speculum was placed in the posterior vaginal vault. The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips.

Obstetrics / Gynecology

Vaginal Hysterectomy

obstetrics / gynecology, omentum, massachusetts, vaginal hysterectomy, vaginal vault, vaginal mucosa, vicryl suture, hysterectomy, ligaments, speculum, ligated, vaginal, sutureNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

10, after, all, also, an

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] None [/TRANSCRIPTION] [TASK_OUTPUT] 10, after, all, also, an [/TASK_OUTPUT] [DESCRIPTION] Vaginal Hysterectomy. A weighted speculum was placed in the posterior vaginal vault. The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips. [/DESCRIPTION] </s>

Extract original key medical terms from this text

urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile,

PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE: ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS: ,Same as above.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:, No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION: ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection. Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified. Once he was anesthetized, the caudal block was placed and IV antibiotics were given. He was then placed in a supine position and sterilely prepped and draped. Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors. We removed the excessive skin on the shaft skin and on the glans itself. We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic. Electrocautery was used for hemostasis. Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again. IV Toradol was given at the end of procedure. The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.

Excision of penile skin bridges about 2 cm in size.

Urology

Penile Skin Bridges Excision

urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile,

the, and, skin, was, used

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE: ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS: ,Same as above.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:, No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION: ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection. Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified. Once he was anesthetized, the caudal block was placed and IV antibiotics were given. He was then placed in a supine position and sterilely prepped and draped. Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors. We removed the excessive skin on the shaft skin and on the glans itself. We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic. Electrocautery was used for hemostasis. Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again. IV Toradol was given at the end of procedure. The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room. [/TRANSCRIPTION] [TASK_OUTPUT] urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile, [/TASK_OUTPUT] [DESCRIPTION] Excision of penile skin bridges about 2 cm in size. [/DESCRIPTION] </s>

Summarize this medical transcription

Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.

PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:, This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,DESCRIPTION OF PROCEDURE:, Consent was obtained after all risks and benefits were described. The patient was brought back into the operating room. The aforementioned anesthesia was given. Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. The incision was extended down using electrocautery. The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. The mass was sent off to Pathology for investigation. Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion. The patient's wound was cleaned. Steri-Strips were placed and sterile dressings were placed on top of this. The patient tolerated the procedure well and will reevaluate in the office in one week's time.

Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.

Surgery

Excision - Soft Tissue Mass

surgery, electrocautery, soft tissue mass, subcutaneous, excision

the, was, and, using, right

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:, This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,DESCRIPTION OF PROCEDURE:, Consent was obtained after all risks and benefits were described. The patient was brought back into the operating room. The aforementioned anesthesia was given. Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. The incision was extended down using electrocautery. The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. The mass was sent off to Pathology for investigation. Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion. The patient's wound was cleaned. Steri-Strips were placed and sterile dressings were placed on top of this. The patient tolerated the procedure well and will reevaluate in the office in one week's time. [/TRANSCRIPTION] [TASK_OUTPUT] Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed. [/TASK_OUTPUT] [DESCRIPTION] Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed. [/DESCRIPTION] </s>

Summarize this medical transcription

Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.

Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

Neurosurgery

Decompressive Laminectomy

neurosurgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,

the, and, was, mm, with

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications. [/TRANSCRIPTION] [TASK_OUTPUT] Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System. [/TASK_OUTPUT] [DESCRIPTION] Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System. [/DESCRIPTION] </s>

Summarize this medical transcription

C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.

PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.

C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.

Neurosurgery

Anterior Cervical Discectomy - 4

neurosurgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,

the, was, we, left, an

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination. [/TRANSCRIPTION] [TASK_OUTPUT] C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy. [/TASK_OUTPUT] [DESCRIPTION] C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, she does not use oxygen at her independent assisted living home. Yesterday, she had made improvement since being here at the hospital. She needed oxygen. She was tested for home O2 and qualified for it yesterday also. Her lungs were very tight. She did have wheezes bilaterally and rhonchi on the right side mostly. She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room. She stated that she needed to urinate. She awoke, decided not to call for assistance. She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker. She attempted to walk to the rest room on her own. She sustained a fall. She stated that she just felt weak. She bumped her knee and her elbow. She had femur x-rays, knee x-rays also. There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side. This morning, she denied any headache, back pain or neck pain. She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS: The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106. She is 95% on 2 L via nasal cannula.,HEART: Regular rate and rhythm without murmur, gallop or rub.,LUNGS: Reveal no expiratory wheezing throughout. She does have some rhonchi on the right mid base. She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN: Soft and nontender. Her bowel sounds x4 are normoactive.,NEUROLOGIC: She is alert and oriented x3. Her pupils are equal and reactive. She has got a good head and facial muscle strength. Her tongue is midline. She has got clear speech. Her extraocular motions are intact. Her spine is nontender on palpation from neck to lumbar spine. She has good range of motion with regard to her shoulders, elbows, wrists and fingers. Her grip strengths are equal bilaterally. Both elbows are strong from extension to flexion. Her hip flexors and extenders are also strong and equal bilaterally. Extension and flexion of the knee bilaterally and ankles also are strong. Palpation of her right knee reveals no crepitus. She does have suprapatellar inflammation with some ecchymosis and swelling. She has got good joint range of motion however.,SKIN: She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1. Acute on chronic COPD exacerbation.,2. Community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.,3. Generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1. I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker. Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2. We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.

Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.

SOAP / Chart / Progress Notes

COPD & Pneumonia - SOAP

soap / chart / progress notes, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd

she, her, and, to, the

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, she does not use oxygen at her independent assisted living home. Yesterday, she had made improvement since being here at the hospital. She needed oxygen. She was tested for home O2 and qualified for it yesterday also. Her lungs were very tight. She did have wheezes bilaterally and rhonchi on the right side mostly. She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room. She stated that she needed to urinate. She awoke, decided not to call for assistance. She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker. She attempted to walk to the rest room on her own. She sustained a fall. She stated that she just felt weak. She bumped her knee and her elbow. She had femur x-rays, knee x-rays also. There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side. This morning, she denied any headache, back pain or neck pain. She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS: The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106. She is 95% on 2 L via nasal cannula.,HEART: Regular rate and rhythm without murmur, gallop or rub.,LUNGS: Reveal no expiratory wheezing throughout. She does have some rhonchi on the right mid base. She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN: Soft and nontender. Her bowel sounds x4 are normoactive.,NEUROLOGIC: She is alert and oriented x3. Her pupils are equal and reactive. She has got a good head and facial muscle strength. Her tongue is midline. She has got clear speech. Her extraocular motions are intact. Her spine is nontender on palpation from neck to lumbar spine. She has good range of motion with regard to her shoulders, elbows, wrists and fingers. Her grip strengths are equal bilaterally. Both elbows are strong from extension to flexion. Her hip flexors and extenders are also strong and equal bilaterally. Extension and flexion of the knee bilaterally and ankles also are strong. Palpation of her right knee reveals no crepitus. She does have suprapatellar inflammation with some ecchymosis and swelling. She has got good joint range of motion however.,SKIN: She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1. Acute on chronic COPD exacerbation.,2. Community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.,3. Generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1. I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker. Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2. We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.48

PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.

Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.

Surgery

Cystoscopy, Ureteropyelogram, & Ureteral Barbotage

surgery, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine,

the, was, right, and, of

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] 0.48 [/TASK_OUTPUT] [DESCRIPTION] Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSIS:,1. Acute bowel obstruction.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1. Acute small bowel obstruction.,2. Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Release of small bowel obstruction.,3. Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:, None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY: ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction. Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia. There was a loop of small bowel incarcerated within the hernia sac. It showed signs of ecchymosis, however no signs of any ischemia or necrosis. It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family. The patient was brought to the operating suite. After general endotracheal intubation, prepped and draped in normal sterile fashion. A midline incision was made around the umbilical hernia defect with a #10 blade scalpel. Dissection was then carried down to the fascia. Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia. The abdomen was entered under direct visualization. The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis. The remaining of the fascia was then extended using Metzenbaum scissors. The hernia sac was removed using Mayo scissors and sent off as specimen. Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities. The small bowel was then milked down removing all the fluid. The bowel was decompressed distal to the obstruction. Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed. The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture. A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition.

Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.

Gastroenterology

Exploratory Laparotomy & Hernia Repair

gastroenterology, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction,

the, was, and, to, of

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:,1. Acute bowel obstruction.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1. Acute small bowel obstruction.,2. Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Release of small bowel obstruction.,3. Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:, None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY: ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction. Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia. There was a loop of small bowel incarcerated within the hernia sac. It showed signs of ecchymosis, however no signs of any ischemia or necrosis. It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family. The patient was brought to the operating suite. After general endotracheal intubation, prepped and draped in normal sterile fashion. A midline incision was made around the umbilical hernia defect with a #10 blade scalpel. Dissection was then carried down to the fascia. Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia. The abdomen was entered under direct visualization. The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis. The remaining of the fascia was then extended using Metzenbaum scissors. The hernia sac was removed using Mayo scissors and sent off as specimen. Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities. The small bowel was then milked down removing all the fluid. The bowel was decompressed distal to the obstruction. Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed. The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture. A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.60

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself.

Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week

Urology

Neurogenic Bladder - Consult

urology, neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,

he, the, has, dr, patient

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself. [/TRANSCRIPTION] [TASK_OUTPUT] 0.60 [/TASK_OUTPUT] [DESCRIPTION] Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week [/DESCRIPTION] </s>

Extract original key medical terms from this text

consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself.

Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week

Consult - History and Phy.

Neurogenic Bladder - Consult

consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,

he, the, has, dr, patient

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself. [/TRANSCRIPTION] [TASK_OUTPUT] consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization, [/TASK_OUTPUT] [DESCRIPTION] Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

H&P - Gen Med - 2

HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,REVIEW OF SYSTEMS:, Review of systems was not obtainable.,PAST MEDICAL HISTORY:, Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,PAST SURGICAL HISTORY:, Noncontributory to above.,FAMILY HISTORY:, Mother with history of coronary artery disease.,SOCIAL HISTORY:, The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit.,MEDICATIONS:, Augmentin; Detrol LA; lisinopril.,IMMUNIZATIONS:, Immunizations were up to date for influenza, negative for Pneumovax.,ALLERGIES:, PENICILLIN.,LABORATORY AT PRESENTATION:, White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4.,RADIOLOGIC DATA:, Chest x-ray revealed a diffuse pulmonary edema.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%.,HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor.,CHEST: Poor air movement bilateral with bilateral rales.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: The abdomen was obese, nondistended and nontender.,EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot.,GU: Foley catheter was in place.,IMPRESSION AND PLAN:,1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.,2. Acute respiratory distress syndrome: Will continue ventilatory support.,3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.,4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.,Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period.

History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.

General Medicine

H&P - Gen Med - 2

and, she, her, the, was

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,REVIEW OF SYSTEMS:, Review of systems was not obtainable.,PAST MEDICAL HISTORY:, Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,PAST SURGICAL HISTORY:, Noncontributory to above.,FAMILY HISTORY:, Mother with history of coronary artery disease.,SOCIAL HISTORY:, The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit.,MEDICATIONS:, Augmentin; Detrol LA; lisinopril.,IMMUNIZATIONS:, Immunizations were up to date for influenza, negative for Pneumovax.,ALLERGIES:, PENICILLIN.,LABORATORY AT PRESENTATION:, White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4.,RADIOLOGIC DATA:, Chest x-ray revealed a diffuse pulmonary edema.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%.,HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor.,CHEST: Poor air movement bilateral with bilateral rales.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: The abdomen was obese, nondistended and nontender.,EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot.,GU: Foley catheter was in place.,IMPRESSION AND PLAN:,1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.,2. Acute respiratory distress syndrome: Will continue ventilatory support.,3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.,4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.,Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period. [/TRANSCRIPTION] [TASK_OUTPUT] H&P - Gen Med - 2 [/TASK_OUTPUT] [DESCRIPTION] History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,3. Alkaline reflux gastritis.,4. Gastroparesis.,5. Probable Billroth II anastomosis.,6. Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass. The patient has pancreatic insufficiency and is already on replacement. She is currently using Nexium. She has continued postprandial dyspepsia and reflux symptoms. To evaluate this, the patient was boarded for EGD. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis. There was no evidence of distal esophagitis. Gastroparesis was seen as there was retained fluid in the small intestine. The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy. Biopsies were taken and further recommendations will follow.,PROCEDURE: ,The patient was taken to the Endoscopy Suite. The heart and lungs examination were unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient's oropharynx was anesthetized with Cetacaine spray. She was placed in left lateral position. The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx. GE junction was in normal position. There was no evidence of any hiatal hernia. There was no evidence of distal esophagitis. The gastric remnant was entered. It was noted to be inflamed with alkaline reflux gastritis. The anastomosis was open and patent. The small intestine was entered. There was retained fluid material in the stomach and small intestine and _______ gastroparesis. Biopsies were performed. Insufflated air was removed with withdrawal of the scope. The patient's diet will be adjusted to postgastrectomy-type diet. Biopsies performed. Diet will be reviewed. The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis. Reglan will also be added. Further recommendations will follow.

Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.

Gastroenterology

Esophagogastroduodenoscopy with Biopsies

gastroenterology, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,

the, was, will, patient, and

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,3. Alkaline reflux gastritis.,4. Gastroparesis.,5. Probable Billroth II anastomosis.,6. Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass. The patient has pancreatic insufficiency and is already on replacement. She is currently using Nexium. She has continued postprandial dyspepsia and reflux symptoms. To evaluate this, the patient was boarded for EGD. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis. There was no evidence of distal esophagitis. Gastroparesis was seen as there was retained fluid in the small intestine. The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy. Biopsies were taken and further recommendations will follow.,PROCEDURE: ,The patient was taken to the Endoscopy Suite. The heart and lungs examination were unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient's oropharynx was anesthetized with Cetacaine spray. She was placed in left lateral position. The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx. GE junction was in normal position. There was no evidence of any hiatal hernia. There was no evidence of distal esophagitis. The gastric remnant was entered. It was noted to be inflamed with alkaline reflux gastritis. The anastomosis was open and patent. The small intestine was entered. There was retained fluid material in the stomach and small intestine and _______ gastroparesis. Biopsies were performed. Insufflated air was removed with withdrawal of the scope. The patient's diet will be adjusted to postgastrectomy-type diet. Biopsies performed. Diet will be reviewed. The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis. Reglan will also be added. Further recommendations will follow. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, was, disease, artery, were

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,

Urgent cardiac catheterization with coronary angiogram.

Cardiovascular / Pulmonary

Urgent Cardiac Cath

cardiovascular / pulmonary, cardiac catheterization, coronary angiogram, angiogram

the, was, disease, artery, were

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram., [/TRANSCRIPTION] [TASK_OUTPUT] the, was, disease, artery, were [/TASK_OUTPUT] [DESCRIPTION] Urgent cardiac catheterization with coronary angiogram. [/DESCRIPTION] </s>

Extract key medical terms from this text

right, the, and, is, left

HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.

Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 6

physical medicine - rehab, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles,

right, the, and, is, left

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future. [/TRANSCRIPTION] [TASK_OUTPUT] right, the, and, is, left [/TASK_OUTPUT] [DESCRIPTION] Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Nasal Septoplasty

PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:, Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL.

Open reduction, nasal fracture with nasal septoplasty.

ENT - Otolaryngology

Nasal Septoplasty

ent - otolaryngology, nasal fracture, deviated nasal septum, nasal septoplasty, nasal bones, ethmoid plate, cartilaginous septum, nasal bone, maxillary crest, septum, nasal, fracture, maxillary, cartilaginous, crest,

the, was, and, left, with

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:, Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL. [/TRANSCRIPTION] [TASK_OUTPUT] Nasal Septoplasty [/TASK_OUTPUT] [DESCRIPTION] Open reduction, nasal fracture with nasal septoplasty. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.

MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.

Orthopedic

MRI Spine - Epidural Lipoma

she, was, and, negative, the

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis. [/DESCRIPTION] </s>

Summarize this medical transcription

Routine colorectal cancer screening. He occasionally gets some loose stools.

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.

Routine colorectal cancer screening. He occasionally gets some loose stools.

Consult - History and Phy.

Colon Cancer Screening

consult - history and phy., colon cancer screening, loose stools, colorectal, colonoscopy,

is, any, no, history, he

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation. [/TRANSCRIPTION] [TASK_OUTPUT] Routine colorectal cancer screening. He occasionally gets some loose stools. [/TASK_OUTPUT] [DESCRIPTION] Routine colorectal cancer screening. He occasionally gets some loose stools. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

CC:, Progressive unsteadiness following head trauma.,HX:, A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.

CT of Brain - Subacute SDH.

Neurology

CT Brain: Subdural hematoma

neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,

he, left, and, right, then

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] CC:, Progressive unsteadiness following head trauma.,HX:, A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] CT of Brain - Subacute SDH. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Cardiovascular / Pulmonary

OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.

Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery.

Cardiovascular / Pulmonary

Subxiphoid Pericardial Window - 1

cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,

the, was, in, and, anesthesia

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied. [/TRANSCRIPTION] [TASK_OUTPUT] Cardiovascular / Pulmonary [/TASK_OUTPUT] [DESCRIPTION] Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,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.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70

Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night.

Neurology

Feet & Hand Cramping

he, his, has, the, and

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,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.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70 [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. There is no shortness of breath and no cough or hemoptysis. No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools. No dysuria, hematuria or excessive urination. No muscle weakness or tenderness. No new numbness or tingling. No arthralgias or arthritis. There are no rashes. No excessive fatigability, loss of motor skills or sensation. No changes in hair texture, change in skin color, excessive or decreased appetite. No swollen lymph nodes or night sweats. No headaches. The rest of the review of systems is negative.

There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing.

Consult - History and Phy.

Normal ROS Template - 1

consult - history and phy., weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

or, no, there, pain, of

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. There is no shortness of breath and no cough or hemoptysis. No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools. No dysuria, hematuria or excessive urination. No muscle weakness or tenderness. No new numbness or tingling. No arthralgias or arthritis. There are no rashes. No excessive fatigability, loss of motor skills or sensation. No changes in hair texture, change in skin color, excessive or decreased appetite. No swollen lymph nodes or night sweats. No headaches. The rest of the review of systems is negative. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. [/DESCRIPTION] </s>

Summarize this medical transcription

A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.

PREOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal fusion.,5. Two previous C-sections. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal effusion.,5. Two previous C-section. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6. Adhesions of bladder.,7. Poor fascia quality.,8. Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1. A repeat low transverse cervical cesarean section.,2. Lysis of adhesions.,3. Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4. The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:, 600 cc.,HISTORY AND INDICATIONS: ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus. The uterus appeared to be intact. This patient is a 26-year-old Caucasian female. The patient is well known to the OB/GYN clinic. The patient had two previous C-sections. She appears to be in probably early labor. She had an amniocentesis early today. She is contracting regularly about every three minutes. The contractions are painful and getting much more so since the amniocentesis. The patient had fetal lung maturity noted. The patient also has probable IUGR as none of her babies have been over 4 lb. The patient's baby appears to be somewhat small. The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound. The patient has had a spinal fusion, however, family planning is definitely complete per the patient. The patient refuses trial labor. The patient and I discussed the consent. She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery. Her questions were answered. The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy. The patient understands this and would like to try our best.,PROCEDURE: ,The patient was taken back to the operative suite. She was given general anesthetic by Department of Anesthesiology. Once again, in layman's terms, the patient understands the risks. The patient had the informed consent reviewed and understood. The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side. The patient had the first knife went through this incision. The second knife was used to go to the level of fascia. The fascia was very thin, ruddy in appearance, and with abundant scar tissue. The fascia was incised. Following this, we were able to see the peritoneum. There was really no obvious rectus abdominal muscles noted. They were very weak, atrophic, and thin. The patient has the peritoneum tented up. We entered the abdominal cavity. The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia. The bladder flap was then entered into the uterus as well. There are some bladder adhesions. We removed these adhesions and we removed the bladder of the fascia. We dissected the bladder of the lower segment. We made a small nick on the lower segment. We were able to utilize the blunt end of the knife to enter into the uterine cavity. The baby was in occiput transverse position with the ear being cocked at such a position as well. The patient's baby was delivered without difficulty. It was a 4 lb and 10 oz baby girl who vigorously cried well. There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection. The patient's placenta was delivered. There was no retained placenta. The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first. The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized. Then we ligated this as there was bleeding and oozing. The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc. The 400 cc was instilled. The bladder appears to be intact. The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment. There was some oozing around the area of the bladder. We placed an Avitene there. The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx. The patient has two clips on each side. There was excellent tubal occlusion and placement. The uterus was placed back into the abdominal cavity. We rechecked again. The tubal placement was excellent. It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx. The patient then underwent further examination. Hemostasis appeared to be good. The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia. We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible. The Scarpa's fascia was reapproximated with #0 gut. The skin was reapproximated then as well via subcutaneous closure. The patient's sponge and needle counts found to be correct. Uterus appeared to be normal prior to closure. Bladder appeared to be normal. The patient's blood loss is 600 cc.

A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.

Obstetrics / Gynecology

Low-Transverse C-Section - 10

obstetrics / gynecology, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal,

the, patient, was, we, to

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal fusion.,5. Two previous C-sections. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal effusion.,5. Two previous C-section. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6. Adhesions of bladder.,7. Poor fascia quality.,8. Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1. A repeat low transverse cervical cesarean section.,2. Lysis of adhesions.,3. Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4. The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:, 600 cc.,HISTORY AND INDICATIONS: ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus. The uterus appeared to be intact. This patient is a 26-year-old Caucasian female. The patient is well known to the OB/GYN clinic. The patient had two previous C-sections. She appears to be in probably early labor. She had an amniocentesis early today. She is contracting regularly about every three minutes. The contractions are painful and getting much more so since the amniocentesis. The patient had fetal lung maturity noted. The patient also has probable IUGR as none of her babies have been over 4 lb. The patient's baby appears to be somewhat small. The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound. The patient has had a spinal fusion, however, family planning is definitely complete per the patient. The patient refuses trial labor. The patient and I discussed the consent. She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery. Her questions were answered. The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy. The patient understands this and would like to try our best.,PROCEDURE: ,The patient was taken back to the operative suite. She was given general anesthetic by Department of Anesthesiology. Once again, in layman's terms, the patient understands the risks. The patient had the informed consent reviewed and understood. The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side. The patient had the first knife went through this incision. The second knife was used to go to the level of fascia. The fascia was very thin, ruddy in appearance, and with abundant scar tissue. The fascia was incised. Following this, we were able to see the peritoneum. There was really no obvious rectus abdominal muscles noted. They were very weak, atrophic, and thin. The patient has the peritoneum tented up. We entered the abdominal cavity. The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia. The bladder flap was then entered into the uterus as well. There are some bladder adhesions. We removed these adhesions and we removed the bladder of the fascia. We dissected the bladder of the lower segment. We made a small nick on the lower segment. We were able to utilize the blunt end of the knife to enter into the uterine cavity. The baby was in occiput transverse position with the ear being cocked at such a position as well. The patient's baby was delivered without difficulty. It was a 4 lb and 10 oz baby girl who vigorously cried well. There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection. The patient's placenta was delivered. There was no retained placenta. The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first. The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized. Then we ligated this as there was bleeding and oozing. The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc. The 400 cc was instilled. The bladder appears to be intact. The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment. There was some oozing around the area of the bladder. We placed an Avitene there. The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx. The patient has two clips on each side. There was excellent tubal occlusion and placement. The uterus was placed back into the abdominal cavity. We rechecked again. The tubal placement was excellent. It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx. The patient then underwent further examination. Hemostasis appeared to be good. The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia. We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible. The Scarpa's fascia was reapproximated with #0 gut. The skin was reapproximated then as well via subcutaneous closure. The patient's sponge and needle counts found to be correct. Uterus appeared to be normal prior to closure. Bladder appeared to be normal. The patient's blood loss is 600 cc. [/TRANSCRIPTION] [TASK_OUTPUT] A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips. [/TASK_OUTPUT] [DESCRIPTION] A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:, Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted.,IMPRESSION:, The patient has some mild benign prostatic hyperplasia. At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.

Microscopic hematuria with lateral lobe obstruction, mild.

Surgery

Flexible Cystoscopy - BPH

surgery, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,

the, will, diagnosis, patient, procedure

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:, Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted.,IMPRESSION:, The patient has some mild benign prostatic hyperplasia. At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Microscopic hematuria with lateral lobe obstruction, mild. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, no, is, and, patient

CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.

A 2-month-old female with 1-week history of congestion and fever x2 days.

Pediatrics - Neonatal

Congestion & Fever - 2-month-old

the, no, is, and, patient

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology. [/TRANSCRIPTION] [TASK_OUTPUT] the, no, is, and, patient [/TASK_OUTPUT] [DESCRIPTION] A 2-month-old female with 1-week history of congestion and fever x2 days. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy

PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties. Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy. The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure. He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection. The tract and the stomach were freed. Stay sutures were then placed on either side of the tract. The tract was amputated. The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures. The fascia was then closed over the stomach using #3-0 Vicryl sutures. The skin was closed with #5-0 subcuticular Monocryl. A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.

Closure of gastrostomy placed due to feeding difficulties.

Surgery

Surgical Closure of Gastrostomy

surgery, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy

the, was, and, then, he

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties. Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy. The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure. He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection. The tract and the stomach were freed. Stay sutures were then placed on either side of the tract. The tract was amputated. The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures. The fascia was then closed over the stomach using #3-0 Vicryl sutures. The skin was closed with #5-0 subcuticular Monocryl. A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy [/TASK_OUTPUT] [DESCRIPTION] Closure of gastrostomy placed due to feeding difficulties. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Phacoemulsification & Cataract Extraction - 1

PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye. She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL: ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart. They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established. MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops. The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia. The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome. A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome. The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves. Each half was further subdivided with chopping and removed with phacoemulsification. The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece. The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty. The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS. The corneal wounds were hydrated and verified to be water-tight. Antibiotic ointment was placed, followed by a patch and shield. The patient was transported to the PACU in good/stable condition. There were no complications. Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.

Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.

Surgery

Phacoemulsification & Cataract Extraction - 1

surgery, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, chamber, phacoemulsification, extraction, visually, anterior, lens

the, was, and, anterior, with

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye. She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL: ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart. They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established. MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops. The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia. The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome. A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome. The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves. Each half was further subdivided with chopping and removed with phacoemulsification. The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece. The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty. The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS. The corneal wounds were hydrated and verified to be water-tight. Antibiotic ointment was placed, followed by a patch and shield. The patient was transported to the PACU in good/stable condition. There were no complications. Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case. [/TRANSCRIPTION] [TASK_OUTPUT] Phacoemulsification & Cataract Extraction - 1 [/TASK_OUTPUT] [DESCRIPTION] Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Intensity-Modulated Radiation Therapy

INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.

Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.

Radiology

Intensity-Modulated Radiation Therapy

radiology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

the, are, is, performed, in

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate. [/TRANSCRIPTION] [TASK_OUTPUT] Intensity-Modulated Radiation Therapy [/TASK_OUTPUT] [DESCRIPTION] Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. [/DESCRIPTION] </s>

Summarize this medical transcription

A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.

SUBJECTIVE:, This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit. After this occurred several times, they stopped giving him carrots. Last week, he ate some celery and the same thing happened. They had not given him any of that since. He eats other foods without any apparent pain or vomiting. Bowel movements are normal. He does have a history of reactive airway disease, intermittently. He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:, He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs: Weight: 31.5 pounds, which is an increase of 2.5 pounds since May. Temperature is 97.1. He certainly appears in no distress. He is quite interested in looking at his books.,Neck: Supple without adenopathy.,Lungs: Clear.,Cardiac: Regular rate and rhythm without murmurs.,Abdomen: Soft without organomegaly, masses, or tenderness.,ASSESSMENT:, Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.,PLAN:, I talked with mother about this. Certainly, it does not suggest any kind of an allergic reaction, nor obstruction. At this time, they will simply avoid those foods. In the future, they may certainly try those again and see how he tolerates those. I did encourage a wide variety of fruits and vegetables in his diet as a general principle. If worsening symptoms, she is welcome to contact me again for reevaluation.

A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.

SOAP / Chart / Progress Notes

Gen Med Progress Note - 6

soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots,

he, his, is, and, this

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit. After this occurred several times, they stopped giving him carrots. Last week, he ate some celery and the same thing happened. They had not given him any of that since. He eats other foods without any apparent pain or vomiting. Bowel movements are normal. He does have a history of reactive airway disease, intermittently. He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:, He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs: Weight: 31.5 pounds, which is an increase of 2.5 pounds since May. Temperature is 97.1. He certainly appears in no distress. He is quite interested in looking at his books.,Neck: Supple without adenopathy.,Lungs: Clear.,Cardiac: Regular rate and rhythm without murmurs.,Abdomen: Soft without organomegaly, masses, or tenderness.,ASSESSMENT:, Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.,PLAN:, I talked with mother about this. Certainly, it does not suggest any kind of an allergic reaction, nor obstruction. At this time, they will simply avoid those foods. In the future, they may certainly try those again and see how he tolerates those. I did encourage a wide variety of fruits and vegetables in his diet as a general principle. If worsening symptoms, she is welcome to contact me again for reevaluation. [/TRANSCRIPTION] [TASK_OUTPUT] A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general. [/TASK_OUTPUT] [DESCRIPTION] A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.66

DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.

Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.

Obstetrics / Gynecology

Breast Radiation Therapy Followup

obstetrics / gynecology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,

her, she, neck, chest, the

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care. [/TRANSCRIPTION] [TASK_OUTPUT] 0.66 [/TASK_OUTPUT] [DESCRIPTION] Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA. [/DESCRIPTION] </s>

Summarize this medical transcription

Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps.

REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.,PAST MEDICAL HISTORY:, Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin. She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.,REVIEW OF SYSTEMS: ,The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:

Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps.

Consult - History and Phy.

Colon Polyps - Genetic Counseling

consult - history and phy., family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps,

she, of, her, history, the

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.,PAST MEDICAL HISTORY:, Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin. She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.,REVIEW OF SYSTEMS: ,The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS: [/TRANSCRIPTION] [TASK_OUTPUT] Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. [/TASK_OUTPUT] [DESCRIPTION] Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. [/DESCRIPTION] </s>

Summarize this medical transcription

Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.

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 to the operating a few days ago for a large right-sided hemicraniectomy to save her life. I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes. I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1. We went to the operating room at that time and we did a very large right-sided hemicraniectomy. The patient was put in the intensive care unit. We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago. Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk. We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift. At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________ this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room. She was already intubated and under general anesthesia. The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder. The patient tolerated this well. We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin. We connected this. Prior to this, we brought in all surgical instrumentation under sterile and standard conditions. We opened the skin as in opening a book and then we also did a myocutaneous flap. We brought in the muscle with it. We had a very good exposure of the skull. We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly. We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side. At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly. All this was irrigated thoroughly. Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely. We had absolutely good hemostasis. We put a piece of Gelfoam over the brain. We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position. I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place. This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely. Once we had done this, irrigated thoroughly once again the skin. We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit. The EBL was about 200 cubic centimeters. Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct. No complications. The patient went back to the intensive care unit.

Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.

Neurosurgery

Hemicraniectomy

neurosurgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE

the, we, and, to, had

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] 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 to the operating a few days ago for a large right-sided hemicraniectomy to save her life. I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes. I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1. We went to the operating room at that time and we did a very large right-sided hemicraniectomy. The patient was put in the intensive care unit. We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago. Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk. We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift. At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________ this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room. She was already intubated and under general anesthesia. The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder. The patient tolerated this well. We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin. We connected this. Prior to this, we brought in all surgical instrumentation under sterile and standard conditions. We opened the skin as in opening a book and then we also did a myocutaneous flap. We brought in the muscle with it. We had a very good exposure of the skull. We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly. We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side. At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly. All this was irrigated thoroughly. Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely. We had absolutely good hemostasis. We put a piece of Gelfoam over the brain. We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position. I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place. This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely. Once we had done this, irrigated thoroughly once again the skin. We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit. The EBL was about 200 cubic centimeters. Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct. No complications. The patient went back to the intensive care unit. [/TRANSCRIPTION] [TASK_OUTPUT] Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. [/TASK_OUTPUT] [DESCRIPTION] Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet.

Elevated cholesterol and is on medication to lower it.

Diets and Nutritions

Dietary Consult - 1

diets and nutritions, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol

he, his, to, is, the

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Elevated cholesterol and is on medication to lower it. [/DESCRIPTION] </s>

Summarize this medical transcription

Barium enema - history of encopresis and constipation.

EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:, The scout radiograph demonstrates a nonobstructive gastrointestinal pattern. There are no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course. There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.

Barium enema - history of encopresis and constipation.

Gastroenterology

Barium Enema

gastroenterology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium,

of, the, normal, is, and

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:, The scout radiograph demonstrates a nonobstructive gastrointestinal pattern. There are no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course. There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema. [/TRANSCRIPTION] [TASK_OUTPUT] Barium enema - history of encopresis and constipation. [/TASK_OUTPUT] [DESCRIPTION] Barium enema - history of encopresis and constipation. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:, Left Chopart joint sprain.,PLAN:, I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.

Consultation for left foot pain.

Consult - History and Phy.

Foot pain Consultation

consult - history and phy., foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness

his, the, he, is, of

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:, Left Chopart joint sprain.,PLAN:, I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Consultation for left foot pain. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1. Dilated cardiomyopathy.,2. Ejection fraction less than 10%.,3. Ventricular tachycardia.,4. Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of biventricular automatic implantable cardioverter defibrillator.,2. Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3. Coronary sinus venogram for left ventricular lead placement.,4. Defibrillation threshold testing x2.,FLUOROSCOPY TIME: ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Vancomycin 1 g (the patient was allergic to penicillin).,2. Versed 10 mg.,3. Fentanyl 100 mcg.,4. Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia. He has underlying sinus bradycardia. Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:, Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks. Guidewires were advanced down into the left axillary vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein. The dilator was removed and another wire was advanced down into the sheath. The sheath was then backed up over the top of the two wires. One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein. The dilator and wire were removed. A defibrillation lead was then advanced down into the atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical septal location. The active fix screw was deployed. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation. The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein. The wire and dilator were removed. An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed. The lead was parked until a later time. Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein. The dilator and wire were removed. A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus. The coronary sinus was cannulated. Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus. A coronary sinus venogram was then performed. It was noted that the most suitable location for lead placement was the middle cardiac vein. This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily. There was no diaphragmatic stimulation. The outer sheath was peeled away. The 9 French sheath was then peeled away. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet. The lead body was turned several times and the lead was affixed to the tissue. Adequate pacing and sensing function were established. A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions. The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2. Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3. Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4. Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 705 ohms. P-waves measured at 1.7 millivolts. Pacing threshold 0.5 volt at 0.4 milliseconds.,2. Right ventricular lead impedance 685 ohms. R-waves measured 10.5 millivolts. Pacing threshold 0.6 volt at 0.4 milliseconds.,3. Left ventricular lead impedance 1098 ohms. R-waves measured 5.2 millivolts. Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1. Shock on T. Charge time 2.9 seconds. Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2. Shock on T. Charge time 2.8 seconds. Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1. A pacing DDD 60 to 120.,2. VT-1 zone 165 beats per minute. VT-2 zone 185 beats per minute. VF zone 205 beats per minute.,CONCLUSIONS,1. Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2. Defibrillation threshold of less than or equal to 17.5 joules.,2. No acute complications.,PLAN,1. The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Device interrogation in the morning.,4. Completion of the course of antibiotics.

Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.

Surgery

Biventricular Cardioverter Defibrillator Implantation

the, was, and, of, to

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1. Dilated cardiomyopathy.,2. Ejection fraction less than 10%.,3. Ventricular tachycardia.,4. Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of biventricular automatic implantable cardioverter defibrillator.,2. Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3. Coronary sinus venogram for left ventricular lead placement.,4. Defibrillation threshold testing x2.,FLUOROSCOPY TIME: ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Vancomycin 1 g (the patient was allergic to penicillin).,2. Versed 10 mg.,3. Fentanyl 100 mcg.,4. Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia. He has underlying sinus bradycardia. Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:, Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks. Guidewires were advanced down into the left axillary vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein. The dilator was removed and another wire was advanced down into the sheath. The sheath was then backed up over the top of the two wires. One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein. The dilator and wire were removed. A defibrillation lead was then advanced down into the atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical septal location. The active fix screw was deployed. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation. The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein. The wire and dilator were removed. An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed. The lead was parked until a later time. Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein. The dilator and wire were removed. A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus. The coronary sinus was cannulated. Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus. A coronary sinus venogram was then performed. It was noted that the most suitable location for lead placement was the middle cardiac vein. This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily. There was no diaphragmatic stimulation. The outer sheath was peeled away. The 9 French sheath was then peeled away. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet. The lead body was turned several times and the lead was affixed to the tissue. Adequate pacing and sensing function were established. A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions. The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2. Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3. Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4. Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 705 ohms. P-waves measured at 1.7 millivolts. Pacing threshold 0.5 volt at 0.4 milliseconds.,2. Right ventricular lead impedance 685 ohms. R-waves measured 10.5 millivolts. Pacing threshold 0.6 volt at 0.4 milliseconds.,3. Left ventricular lead impedance 1098 ohms. R-waves measured 5.2 millivolts. Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1. Shock on T. Charge time 2.9 seconds. Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2. Shock on T. Charge time 2.8 seconds. Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1. A pacing DDD 60 to 120.,2. VT-1 zone 165 beats per minute. VT-2 zone 185 beats per minute. VF zone 205 beats per minute.,CONCLUSIONS,1. Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2. Defibrillation threshold of less than or equal to 17.5 joules.,2. No acute complications.,PLAN,1. The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Device interrogation in the morning.,4. Completion of the course of antibiotics. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Hysterectomy (TAH - BSO)

PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:, Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:, General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy. She was counseled to undergo staging laparotomy.,FINDINGS:, Examination under anesthesia revealed a small uterus with no nodularity. During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease. Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal. There was no evidence of residual neoplasm after removal of the uterus. The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place. Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided. The peritoneum was entered without difficulty and washings were obtained. The abdomen was explored with findings as noted. A Bookwalter retractor was placed and bowel was packed. Clamps were placed on the broad ligament for traction. The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament. The round ligaments were isolated, divided, and ligated. The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters. The infundibulopelvic ligaments were isolated, divided, and doubly ligated. The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated. Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated. When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries. Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches. The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy. Metzenbaum scissors were used to incise lymphatic tissues. Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially. The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally. Ligaclips were applied where necessary. After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes. Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised. The pelvis was again irrigated and excellent hemostasis was noted. The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture. Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed. Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch. The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.

Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.

Obstetrics / Gynecology

Hysterectomy (TAH - BSO)

obstetrics / gynecology, tah, bso, lymphadenectomy, endometrial, total abdominal hysterectomy, bilateral salpingo oophorectomy, tubes and ovaries, salpingo oophorectomy, lymph nodes, endometrial cancer, abdominal, hysterectomy, oophorectomy, hemostasis, retractors, washings, laparotomy, ligated, pelvic, uterus, nodes,

the, was, and, were, of

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:, Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:, General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy. She was counseled to undergo staging laparotomy.,FINDINGS:, Examination under anesthesia revealed a small uterus with no nodularity. During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease. Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal. There was no evidence of residual neoplasm after removal of the uterus. The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place. Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided. The peritoneum was entered without difficulty and washings were obtained. The abdomen was explored with findings as noted. A Bookwalter retractor was placed and bowel was packed. Clamps were placed on the broad ligament for traction. The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament. The round ligaments were isolated, divided, and ligated. The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters. The infundibulopelvic ligaments were isolated, divided, and doubly ligated. The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated. Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated. When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries. Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches. The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy. Metzenbaum scissors were used to incise lymphatic tissues. Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially. The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally. Ligaclips were applied where necessary. After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes. Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised. The pelvis was again irrigated and excellent hemostasis was noted. The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture. Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed. Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch. The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Hysterectomy (TAH - BSO) [/TASK_OUTPUT] [DESCRIPTION] Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.60

PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.

Left axillary lymph node excisional biopsy. Left axillary adenopathy.

Hematology - Oncology

Lymph Node Excisional Biopsy

hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy

the, was, her, she, and

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] 0.60 [/TASK_OUTPUT] [DESCRIPTION] Left axillary lymph node excisional biopsy. Left axillary adenopathy. [/DESCRIPTION] </s>

Summarize this medical transcription

Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.

PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.

Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.

Neurosurgery

Lumbar Laminotomy & Discectomy

neurosurgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,

the, was, and, to, of

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications. [/TRANSCRIPTION] [TASK_OUTPUT] Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left. [/TASK_OUTPUT] [DESCRIPTION] Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left. [/DESCRIPTION] </s>

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the, of, right, and, mm

EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above.

Frontal and lateral views of the hip and pelvis.

Radiology

Slipped Capital Femoral Epiphysis (SCFE)

radiology, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

the, of, right, and, mm

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above. [/TRANSCRIPTION] [TASK_OUTPUT] the, of, right, and, mm [/TASK_OUTPUT] [DESCRIPTION] Frontal and lateral views of the hip and pelvis. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

MRI L-S Spine - Cauda Equina Syndrome

CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but "non-surgical" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.

MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.

Neurology

MRI L-S Spine - Cauda Equina Syndrome

neurology, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness,

he, on, the, to, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but "non-surgical" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC. [/TRANSCRIPTION] [TASK_OUTPUT] MRI L-S Spine - Cauda Equina Syndrome [/TASK_OUTPUT] [DESCRIPTION] MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness. [/DESCRIPTION] </s>

Summarize this medical transcription

Bilateral vasovasostomy surgery sample.

Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens. This incision was carried down to the area of the previous vasectomy. A towel clip was placed around this. Next the scarred area was dissected free back to normal vas proximally and distally. Approximately 4 cm of vas was freed up. Next the vas was amputated above and below the scar tissue. Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends. Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully. After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed. Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen. This was all done with 3.5 loupe magnification. Next the vas ends were pulled together by tying the sutures. A good reapproximation was noted. Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum. The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition. Antibiotic ointment, fluffs, and a scrotal support were placed.

Bilateral vasovasostomy surgery sample.

Surgery

Bilateral Vasovasostomy

surgery, vasovasostomy, adventitial tissue, anastomosis, fluffs, hemiscrotum, loupe magnification, lumen, muscle layer, scrotal support, subcuticular, vas deferens, vas ends, bilateral vasovasostomy, chromic, suturesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

the, was, and, were, to

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens. This incision was carried down to the area of the previous vasectomy. A towel clip was placed around this. Next the scarred area was dissected free back to normal vas proximally and distally. Approximately 4 cm of vas was freed up. Next the vas was amputated above and below the scar tissue. Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends. Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully. After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed. Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen. This was all done with 3.5 loupe magnification. Next the vas ends were pulled together by tying the sutures. A good reapproximation was noted. Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum. The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition. Antibiotic ointment, fluffs, and a scrotal support were placed. [/TRANSCRIPTION] [TASK_OUTPUT] Bilateral vasovasostomy surgery sample. [/TASK_OUTPUT] [DESCRIPTION] Bilateral vasovasostomy surgery sample. [/DESCRIPTION] </s>

Extract key medical terms from this text

he, the, was, his, of

HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. 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.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76

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.

Neurology

Diplopia

he, the, was, his, of

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. 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.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76 [/TRANSCRIPTION] [TASK_OUTPUT] he, the, was, his, of [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids

PREOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:, Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:, General.,HISTORY: , The patient is 5-1/2 years old. She is here this morning with her Mom. She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well. At the office we saw the tonsils were very big. There was a rock in the right ear and it was very deep in the canal, near the drum. We will remove the foreign body under the same anesthetic.,PROCEDURE:,: Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B. I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum. On the right side, I took out some impacted wax and removed the rock with a large suction. It was actually resting on the surface of the drum but had not scarred or damaged the drum. The drum was intact with no evidence of middle ear fluid. The microscope was set aside. Afrin drops were placed in both nostrils. The neck was gently extended and the Crowe-Davis mouth gag inserted. The tonsils and adenoids were very large. The uvula was intact. Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx. Tonsillectomy accomplished by sharp and blunt dissection. Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine. Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds. Sponge is removed from the nasopharynx. The suction electrocautery was used for pinpoint hemostasis on the adenoid bed. We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices. The nose and throat were then irrigated with saline and suctioned. Excellent hemostasis was observed. An orogastric tube was placed. The stomach found to be empty. The tube was removed, as was the mouth gag. Sponge and needle count were reported correct. The child was then awakened and prepared for her to return to the recovery room. She tolerated the operation excellently.

Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.

Surgery

Tonsillectomy & Adenoidectomy

surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids

the, and, was, with, of

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:, Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:, General.,HISTORY: , The patient is 5-1/2 years old. She is here this morning with her Mom. She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well. At the office we saw the tonsils were very big. There was a rock in the right ear and it was very deep in the canal, near the drum. We will remove the foreign body under the same anesthetic.,PROCEDURE:,: Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B. I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum. On the right side, I took out some impacted wax and removed the rock with a large suction. It was actually resting on the surface of the drum but had not scarred or damaged the drum. The drum was intact with no evidence of middle ear fluid. The microscope was set aside. Afrin drops were placed in both nostrils. The neck was gently extended and the Crowe-Davis mouth gag inserted. The tonsils and adenoids were very large. The uvula was intact. Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx. Tonsillectomy accomplished by sharp and blunt dissection. Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine. Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds. Sponge is removed from the nasopharynx. The suction electrocautery was used for pinpoint hemostasis on the adenoid bed. We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices. The nose and throat were then irrigated with saline and suctioned. Excellent hemostasis was observed. An orogastric tube was placed. The stomach found to be empty. The tube was removed, as was the mouth gag. Sponge and needle count were reported correct. The child was then awakened and prepared for her to return to the recovery room. She tolerated the operation excellently. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids [/TASK_OUTPUT] [DESCRIPTION] Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear. [/DESCRIPTION] </s>

Summarize this medical transcription

A 32-year-old male with shoulder pain.

EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.

A 32-year-old male with shoulder pain.

Orthopedic

MRI Shoulder - 3

orthopedic, impinging lesion, os acromiale, shoulder, tendon, acromiale, osseous

there, the, is, normal, of

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear. [/TRANSCRIPTION] [TASK_OUTPUT] A 32-year-old male with shoulder pain. [/TASK_OUTPUT] [DESCRIPTION] A 32-year-old male with shoulder pain. [/DESCRIPTION] </s>

Extract original key medical terms from this text

orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion

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-C5.,4. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position. The neck was prepped and draped in the usual fashion for anterior cervical discectomy. A high incision was made to allow access to C2-C3. Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate. We placed in self-retaining retractors. With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5. After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal. In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4. We then placed the ABC 55-mm plate from C2 down to C4. These were secured with 16-mm titanium screws after excellent purchase. We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin. Blood loss was about 50 mL. No complication of the surgery. Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation. At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.

Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.

Orthopedic

Anterior Cervical Discectomy & Fusion - 1

orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion

the, and, we, was, to

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] 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-C5.,4. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position. The neck was prepped and draped in the usual fashion for anterior cervical discectomy. A high incision was made to allow access to C2-C3. Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate. We placed in self-retaining retractors. With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5. After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal. In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4. We then placed the ABC 55-mm plate from C2 down to C4. These were secured with 16-mm titanium screws after excellent purchase. We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin. Blood loss was about 50 mL. No complication of the surgery. Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation. At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form. [/TRANSCRIPTION] [TASK_OUTPUT] orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion [/TASK_OUTPUT] [DESCRIPTION] Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Urgent Cardiac Cath

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,

Urgent cardiac catheterization with coronary angiogram.

Emergency Room Reports

Urgent Cardiac Cath

emergency room reports, cardiac catheterization, coronary angiogram, angiogram

the, was, disease, artery, were

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram., [/TRANSCRIPTION] [TASK_OUTPUT] Urgent Cardiac Cath [/TASK_OUTPUT] [DESCRIPTION] Urgent cardiac catheterization with coronary angiogram. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1. Arthroscopic lateral meniscoplasty.,2. Patellar shaving of the right knee.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:, Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE: ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position. Department of Anesthesia administered general anesthetic to the patient. All bony prominences were well padded at this time. The right lower extremity was then properly positioned in a Johnson knee holder. At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions. The right lower extremity was then sterilely prepped and draped in usual sterile fashion. Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon. The cannula and trocar were then inserted through this, putting the patellofemoral joint. An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch. Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella. There were no loose bodies noted in the either gutter. Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted. While in this area, attention was directed to establish the inferomedial instrument portal. This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line. A probe was then inserted through this portal and the meniscus was further probed. Again, there was noted to be no meniscal tear. The knee was taken through range of motion and there was no chondromalacia. Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign. PCL was also noted to be intact. Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns. It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle. An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus. It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee. Pictures were taken both pre-meniscal resection and post-meniscal resection. The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured. The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact. Next, attention was directed to the inner surface of the patella. This was debrided using the 2.5 arthroscopic shaver. It was noted to be quite smooth and postprocedure the patient was taken ________ well. The knee was then copiously irrigated and suctioned dry and all instrumentation was removed. 20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity. At this time, Department of Anesthesia reversed the anesthetic. The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure and there were no complications.

Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.

Surgery

Arthroscopic Meniscoplasty

surgery, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus,

the, was, and, then, of

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1. Arthroscopic lateral meniscoplasty.,2. Patellar shaving of the right knee.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:, Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE: ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position. Department of Anesthesia administered general anesthetic to the patient. All bony prominences were well padded at this time. The right lower extremity was then properly positioned in a Johnson knee holder. At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions. The right lower extremity was then sterilely prepped and draped in usual sterile fashion. Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon. The cannula and trocar were then inserted through this, putting the patellofemoral joint. An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch. Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella. There were no loose bodies noted in the either gutter. Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted. While in this area, attention was directed to establish the inferomedial instrument portal. This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line. A probe was then inserted through this portal and the meniscus was further probed. Again, there was noted to be no meniscal tear. The knee was taken through range of motion and there was no chondromalacia. Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign. PCL was also noted to be intact. Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns. It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle. An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus. It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee. Pictures were taken both pre-meniscal resection and post-meniscal resection. The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured. The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact. Next, attention was directed to the inner surface of the patella. This was debrided using the 2.5 arthroscopic shaver. It was noted to be quite smooth and postprocedure the patient was taken ________ well. The knee was then copiously irrigated and suctioned dry and all instrumentation was removed. 20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity. At this time, Department of Anesthesia reversed the anesthetic. The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure and there were no complications. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X. This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:, She was admitted. She was 3 cm dilated on admission. She desired induction of labor. Therefore, Pitocin was started. Epidural was placed for labor pain. She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy. She remained febrile, approximately 100.3. She then progressed. On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated. She had reported previously some mucous discharge with no ruptured membranes. Upon my exam, no membranes were noted. Attempted artificial rupture of membranes was performed. No fluid noted and there was no fluid discharge noted all the way until the time of delivery. Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor. She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:, Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise. Placenta delivery spontaneous. Condition was intact with a three-vessel cord. Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration. These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively. Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal. Apgars were 0 and 0. Weight pending at this time.,NARRATIVE OF DELIVERY:, I was called. This patient was completely dilated. I arrived. She pushed for three contractions. She was very comfortable. She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant. There was a tight nuchal cord x1 that was reduced after delivery of the fetus. Cord was doubly clamped. The infant was transferred to a bassinet cleaned by the nursing staff en route. The placenta delivered spontaneously, was carefully examined, found to be intact. No signs of abruption. No signs of abnormal placentation or abnormal cord insertion. The cord was examined and a three-vessel cord was confirmed. At this time, IV Pitocin and bimanual massage. Fundus firm as above with minimal postpartum bleeding. The vagina and perineum were carefully inspected. A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture. At this time, the repair is intact. She is hemostatic. All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time. We have called pastor in to baptize the baby as well as calling social work. They are deciding on a burial versus cremation, have decided against autopsy at this time. She will be transferred to postpartum for her recovery. She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise. I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.

Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.

Obstetrics / Gynecology

Delivery Note

obstetrics / gynecology, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal

was, she, the, and, time

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X. This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:, She was admitted. She was 3 cm dilated on admission. She desired induction of labor. Therefore, Pitocin was started. Epidural was placed for labor pain. She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy. She remained febrile, approximately 100.3. She then progressed. On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated. She had reported previously some mucous discharge with no ruptured membranes. Upon my exam, no membranes were noted. Attempted artificial rupture of membranes was performed. No fluid noted and there was no fluid discharge noted all the way until the time of delivery. Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor. She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:, Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise. Placenta delivery spontaneous. Condition was intact with a three-vessel cord. Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration. These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively. Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal. Apgars were 0 and 0. Weight pending at this time.,NARRATIVE OF DELIVERY:, I was called. This patient was completely dilated. I arrived. She pushed for three contractions. She was very comfortable. She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant. There was a tight nuchal cord x1 that was reduced after delivery of the fetus. Cord was doubly clamped. The infant was transferred to a bassinet cleaned by the nursing staff en route. The placenta delivered spontaneously, was carefully examined, found to be intact. No signs of abruption. No signs of abnormal placentation or abnormal cord insertion. The cord was examined and a three-vessel cord was confirmed. At this time, IV Pitocin and bimanual massage. Fundus firm as above with minimal postpartum bleeding. The vagina and perineum were carefully inspected. A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture. At this time, the repair is intact. She is hemostatic. All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time. We have called pastor in to baptize the baby as well as calling social work. They are deciding on a burial versus cremation, have decided against autopsy at this time. She will be transferred to postpartum for her recovery. She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise. I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed.

Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.

Podiatry

Bunionectomy & Metatarsal Osteotomy

podiatry, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,

the, was, then, to, with

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Extraoral I&D

PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:, Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:, One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE: ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally __________ suction. The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point, the procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transported to PACU in good condition.

Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.

Dentistry

Extraoral I&D

dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth,

the, was, and, of, left

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:, Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:, One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE: ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally __________ suction. The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point, the procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transported to PACU in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] Extraoral I&D [/TASK_OUTPUT] [DESCRIPTION] Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy. He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:, No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:, He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL: Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT: No scleral icterus.,NECK: No cervical, supraclavicular, or axillary adenopathy.,LUNGS: Clear.,HEART: Regular. No murmurs or gallops.,ABDOMEN: As noted, obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES: ,Normal sinus rhythm on EKG, prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:, Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.

Patient with intermittent episodes of severe nausea and abdominal pain.

Consult - History and Phy.

Gen Med Consult - 29

consult - history and phy., sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent,

he, the, was, history, for

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy. He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:, No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:, He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL: Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT: No scleral icterus.,NECK: No cervical, supraclavicular, or axillary adenopathy.,LUNGS: Clear.,HEART: Regular. No murmurs or gallops.,ABDOMEN: As noted, obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES: ,Normal sinus rhythm on EKG, prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:, Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Patient with intermittent episodes of severe nausea and abdominal pain. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.64

LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.,CONCLUSION: ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1. Normal stress/rest cardiac perfusion with no indication of ischemia.,2. Normal LV function and low likelihood of significant epicardial coronary narrowing.,

Lexiscan myoview stress study. Chest discomfort. Normal stress/rest cardiac perfusion with no indication of ischemia. Normal LV function and low likelihood of significant epicardial coronary narrowing.

Radiology

Mayoview - 2

radiology, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,

the, of, and, with, normal

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.,CONCLUSION: ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1. Normal stress/rest cardiac perfusion with no indication of ischemia.,2. Normal LV function and low likelihood of significant epicardial coronary narrowing., [/TRANSCRIPTION] [TASK_OUTPUT] 0.64 [/TASK_OUTPUT] [DESCRIPTION] Lexiscan myoview stress study. Chest discomfort. Normal stress/rest cardiac perfusion with no indication of ischemia. Normal LV function and low likelihood of significant epicardial coronary narrowing. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE: ,The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself.

Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.

General Medicine

Chronic Abscesses - Discharge Summary

general medicine, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics,

he, his, to, was, right

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE: ,The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh. [/DESCRIPTION] </s>

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PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:, Breast mass, left.,PROCEDURE:, Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Preoperative antibiotic was given. The patient was prepped and draped in the usual fashion. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc. Hemostasis was achieved with the cautery. The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl. A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.

Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin.

Obstetrics / Gynecology

Breast Mass Excision - 2

obstetrics / gynecology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,

the, was, and, left, skin

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:, Breast mass, left.,PROCEDURE:, Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Preoperative antibiotic was given. The patient was prepped and draped in the usual fashion. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc. Hemostasis was achieved with the cautery. The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl. A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. [/DESCRIPTION] </s>

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Shorter than average

CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission. The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting. The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction. The patient was subsequently admitted for possible obstruction. The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.) He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily. Esophageal reflux treated with Nexium 40 mg daily. Allergic rhinitis treated with Allegra 180 mg daily. Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly. Glaucoma treated with Xalatan drops. History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES: ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of "old age," mother died at age 89 of "old age." Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY: ,The patient is widowed and a retired engineer. He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss. HEENT: Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat. Neck: Denies neck stiffness, no pain or masses in the neck. Respiratory: Denies cough, sputum production, hemoptysis, wheezing or shortness of breath. Cardiovascular: Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation. Gastrointestinal: See history of the present illness. Urinary: Denies dysuria, frequency, urgency or hematuria. Neuro: Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL: The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT: Atraumatic, normocephalic. Eyes, EOMs full, PERRLA. Fundi benign. TMs normal. Nose clear. Throat benign.,NECK: Supple with no adenopathy. Carotid upstrokes normal with no bruits. Thyroid is not enlarged.,LUNGS: Clear to percussion and auscultation.,HEART: Regular rate, normal S1 and S2 with no murmurs or gallops. PMI is nondisplaced.,ABDOMEN: Mildly distended with mild diffuse tenderness. There is no rebound or guarding. Bowel sounds are hypoactive.,EXTREMITIES: No cyanosis, clubbing or edema. Pulses are strong and intact throughout.,GENITALIA: Atrophic male, no scrotal masses or tenderness. Testicles are atrophic. No hernia is noted.,RECTAL: Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:, WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000. Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44. Alkaline phosphatase, AST and ALT are all normal. UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1. Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2. Hypertension.,3. Esophageal reflux.,4. Allergic rhinitis.,5. Glaucoma.,PLAN: , The patient is admitted to the medical floor. He has been kept NPO and will be given IV fluids. He will also be given antiemetic medications with Zofran and an analgesic as necessary. General surgery consultation was obtained. Abdominal series x-ray will be done.

Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction. The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.

Consult - History and Phy.

Gen Med Consult - 51

and, or, he, the, mg

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission. The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting. The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction. The patient was subsequently admitted for possible obstruction. The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.) He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily. Esophageal reflux treated with Nexium 40 mg daily. Allergic rhinitis treated with Allegra 180 mg daily. Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly. Glaucoma treated with Xalatan drops. History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES: ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of "old age," mother died at age 89 of "old age." Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY: ,The patient is widowed and a retired engineer. He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss. HEENT: Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat. Neck: Denies neck stiffness, no pain or masses in the neck. Respiratory: Denies cough, sputum production, hemoptysis, wheezing or shortness of breath. Cardiovascular: Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation. Gastrointestinal: See history of the present illness. Urinary: Denies dysuria, frequency, urgency or hematuria. Neuro: Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL: The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT: Atraumatic, normocephalic. Eyes, EOMs full, PERRLA. Fundi benign. TMs normal. Nose clear. Throat benign.,NECK: Supple with no adenopathy. Carotid upstrokes normal with no bruits. Thyroid is not enlarged.,LUNGS: Clear to percussion and auscultation.,HEART: Regular rate, normal S1 and S2 with no murmurs or gallops. PMI is nondisplaced.,ABDOMEN: Mildly distended with mild diffuse tenderness. There is no rebound or guarding. Bowel sounds are hypoactive.,EXTREMITIES: No cyanosis, clubbing or edema. Pulses are strong and intact throughout.,GENITALIA: Atrophic male, no scrotal masses or tenderness. Testicles are atrophic. No hernia is noted.,RECTAL: Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:, WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000. Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44. Alkaline phosphatase, AST and ALT are all normal. UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1. Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2. Hypertension.,3. Esophageal reflux.,4. Allergic rhinitis.,5. Glaucoma.,PLAN: , The patient is admitted to the medical floor. He has been kept NPO and will be given IV fluids. He will also be given antiemetic medications with Zofran and an analgesic as necessary. General surgery consultation was obtained. Abdominal series x-ray will be done. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction. The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. [/DESCRIPTION] </s>

Summarize this medical transcription

Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1. Coronary artery disease, status post stent placement two years ago.,2. Diabetes mellitus for the last 12 years.,3. Hypertension.,4. End-stage renal disease.,5. History of TIA in the past.,PAST SURGICAL HISTORY:,1. As mentioned above.,2. Cholecystectomy.,3. Appendectomy.,4. Right IJ PermaCath placement.,5. AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:, He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES: ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL: He is alert, seems to be in no apparent distress.,VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT: Atraumatic and normocephalic.,NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS: Clear to auscultation. Air entry bilateral equal.,HEART: S1 and S2. No pericardial rub.,ABDOMEN: Soft and nontender. Normal bowel sounds.,EXTREMITIES: No edema.,NEUROLOGIC: The patient is alert without focal deficit.,LABORATORY DATA:, Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1. End-stage renal disease, plan for dialysis today.,2. Diabetes mellitus.,3. Chest pain for coronary angiogram today.,4. Hypertension, blood pressure stable.,PLAN: , Currently follow the patient. Dr. Z is going to assume the care.

Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

Nephrology

End Stage Renal Disease - Consult

he, disease, history, the, chest

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1. Coronary artery disease, status post stent placement two years ago.,2. Diabetes mellitus for the last 12 years.,3. Hypertension.,4. End-stage renal disease.,5. History of TIA in the past.,PAST SURGICAL HISTORY:,1. As mentioned above.,2. Cholecystectomy.,3. Appendectomy.,4. Right IJ PermaCath placement.,5. AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:, He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES: ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL: He is alert, seems to be in no apparent distress.,VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT: Atraumatic and normocephalic.,NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS: Clear to auscultation. Air entry bilateral equal.,HEART: S1 and S2. No pericardial rub.,ABDOMEN: Soft and nontender. Normal bowel sounds.,EXTREMITIES: No edema.,NEUROLOGIC: The patient is alert without focal deficit.,LABORATORY DATA:, Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1. End-stage renal disease, plan for dialysis today.,2. Diabetes mellitus.,3. Chest pain for coronary angiogram today.,4. Hypertension, blood pressure stable.,PLAN: , Currently follow the patient. Dr. Z is going to assume the care. [/TRANSCRIPTION] [TASK_OUTPUT] Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain. [/TASK_OUTPUT] [DESCRIPTION] Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain. [/DESCRIPTION] </s>

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DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.

Discharge summary of a patient with depression and high risk behavior.

Discharge Summary

Psychiatric Discharge Summary - 2

this, at, is, the, of

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Discharge summary of a patient with depression and high risk behavior. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,POSTOPERATIVE:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,4. Delivery of a viable female, weight 5 pound, 14 ounces. Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:, Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS: ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction. The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department. The patient was then repositioned, prepped and draped in a slight left lateral tilt. Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in transverse fashion. Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique. The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. Presenting part was vertex, the head was delivered, followed by the remaining portion of the body. The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. Cord pH blood and cord blood was obtained. The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. This area was then irrigated. Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center. Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl. Skin edges reapproximated with sterile staples. Sterile dressing was applied. The uterus was evacuated of any remaining clots vaginally. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.

Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.

Surgery

Low-Transverse C-Section - 2

surgery, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine

the, and, was, with, of

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,POSTOPERATIVE:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,4. Delivery of a viable female, weight 5 pound, 14 ounces. Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:, Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS: ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction. The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department. The patient was then repositioned, prepped and draped in a slight left lateral tilt. Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in transverse fashion. Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique. The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. Presenting part was vertex, the head was delivered, followed by the remaining portion of the body. The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. Cord pH blood and cord blood was obtained. The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. This area was then irrigated. Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center. Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl. Skin edges reapproximated with sterile staples. Sterile dressing was applied. The uterus was evacuated of any remaining clots vaginally. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate. [/DESCRIPTION] </s>

Summarize this medical transcription

Open cholecystectomy (attempted laparoscopic cholecystectomy).

PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.

Open cholecystectomy (attempted laparoscopic cholecystectomy).

Gastroenterology

Cholecystectomy - Open

gastroenterology, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french,

was, the, and, placed, to

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Open cholecystectomy (attempted laparoscopic cholecystectomy). [/TASK_OUTPUT] [DESCRIPTION] Open cholecystectomy (attempted laparoscopic cholecystectomy). [/DESCRIPTION] </s>

Summarize this medical transcription

Psychosocial evaluation of kidney donor. Questions - Answers

DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes."

Psychosocial evaluation of kidney donor. Questions - Answers

Psychiatry / Psychology

Psychosocial Eval - Donor

have, and, the, that, is

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes." [/TRANSCRIPTION] [TASK_OUTPUT] Psychosocial evaluation of kidney donor. Questions - Answers [/TASK_OUTPUT] [DESCRIPTION] Psychosocial evaluation of kidney donor. Questions - Answers [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.

HCT: SAH, Contusion, Skull fracture

Neurology

SAH, Contusion, Skull Fracture

neurology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture,

he, and, his, was, the

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] HCT: SAH, Contusion, Skull fracture [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.49

PREOPERATIVE DIAGNOSIS: ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2. Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:, None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:, 25 mL.,ANESTHESIA: , General.,INDICATIONS: ,The patient suffered injury at which time he fell over a concrete bench. He landed mostly on the right arm. He noted some bleeding at the time of the injury and a small puncture wound. He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure. This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well. Risks and benefits were also discussed. Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. They understood these well. 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 middle one-third overlying the radial one-half. There was bleeding in this region. No gross contamination was seen. At this point, under fluoroscopic control, I did attempt to see a fracture. I was unable to do the forearm under the close reduction techniques. At this point, the right upper extremity was then prepped and draped in the usual sterile manner. An incision was made through the puncture wound site extending this proximally and distally. There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed. I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed. These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound. Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution. All nonviable gross contaminated tissue was removed. At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation. Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously. The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated. Hemostasis confirmed and closure then begun. The skin was reapproximated using 3-0 nylon suture. The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform. Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied. X-ray with fluoroscopic evaluation was performed, which confirmed. They maintained excellent bony approximation and the anatomic alignment. The long-arm cast was then completely mature. No complications were encountered throughout the procedure. The patient tolerated the procedure well. The patient was then taken to the recovery room in stable condition.

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.

Surgery

I&D & Open Reduction - Forearm

surgery, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture,

the, was, and, of, this

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2. Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:, None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:, 25 mL.,ANESTHESIA: , General.,INDICATIONS: ,The patient suffered injury at which time he fell over a concrete bench. He landed mostly on the right arm. He noted some bleeding at the time of the injury and a small puncture wound. He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure. This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well. Risks and benefits were also discussed. Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. They understood these well. 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 middle one-third overlying the radial one-half. There was bleeding in this region. No gross contamination was seen. At this point, under fluoroscopic control, I did attempt to see a fracture. I was unable to do the forearm under the close reduction techniques. At this point, the right upper extremity was then prepped and draped in the usual sterile manner. An incision was made through the puncture wound site extending this proximally and distally. There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed. I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed. These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound. Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution. All nonviable gross contaminated tissue was removed. At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation. Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously. The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated. Hemostasis confirmed and closure then begun. The skin was reapproximated using 3-0 nylon suture. The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform. Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied. X-ray with fluoroscopic evaluation was performed, which confirmed. They maintained excellent bony approximation and the anatomic alignment. The long-arm cast was then completely mature. No complications were encountered throughout the procedure. The patient tolerated the procedure well. The patient was then taken to the recovery room in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] 0.49 [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.

Repair of bilateral cleft of the palate with vomer flaps.

Surgery

Cleft Repair

surgery, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,

the, of, was, and, with

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Repair of bilateral cleft of the palate with vomer flaps. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

SUBJECTIVE:, The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. She follows with Dr. XYZ on her hypertension, as well as myself. She continues to gain weight. Diabetes is therefore a major concern. In fact, her dad had diabetes and she has a brother who has diabetes. The patient also has several additional concerns she brings up today. One is that her left knee continues to bother her and it hurts. She cannot really isolate where the pain is, it just seems to hurt through her knee. She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999. There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially. She would like to have this x-rayed again today. She is certainly not interested in any surgery. She has noted that it particularly hurts to kneel. In addition, she complains of her stools being a baby-yellow. She has rectal bleeding off and on. It is bright red. She had a colonoscopy done in 1999. She does have a family history of colon cancer questionable in her mother, who is deceased. She complains of some diffuse abdominal pain off and on. She has given up fast foods and her pop and this has not seemed to help. She does admit however, that she is not eating right. Sometimes her stools are hard. Sometimes they are runny. The blood does not really seem to be related to necessarily a hard stool. It is always bright red and will sometimes drip into the toilet. Over the last couple of days, she had also been sneezing and has had an itchy throat. She tried some Claritin and this did not help. She has had some body aches. She is finally feeling better today with this. She also is questioning whether she has some sleep apnea. She will awaken suddenly in the middle of the night. She was told that she does snore. She does not smoke. As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy.,PREVENTATIVE HISTORY:, She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:, Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:, Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:, Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General: Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals: Her weight today is 246 pounds. In March of 2002 she weighed 231 pounds. In March 2001 she weighed 203 pounds. Her blood pressure is 160/78. Pulse is 84. Respiratory rate of 20. She is afebrile.,HEENT: Head is of normocephalic, atraumatic. PERLA. Conjunctivae clear. TMs are unremarkable and canals are patent. Nasal mucosa is slightly reddened. Nares are patent. Throat shows some clear posterior pharyngeal drainage. Throat is slightly reddened. Non-exudative. No oral lesions or dental caries noted.,Neck: Supple, No adenopathy. Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart: Regular rate and rhythm without murmurs, clicks or rubs. PMI is nondisplaced.,Lungs: Clear to A&P. No CVA tenderness.,Breast exam: Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge. Breasts were examined both lying and sitting.,Abdomen: Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses. Non tender.,Pelvic exam: BUS unremarkable. Speculum exam shows normal physiologic discharge. There are some atrophic vaginal changes. Cervix visualized, no gross abnormalities. Pap smear obtained. Bimanual is negative for any adnexal masses or tenderness. Rectal exam is negative for any adnexal masses or tenderness. No rectal masses. She does have some external hemorrhoids, none of which are inflamed at this time. No palpable rectal masses.,Neuromusculoskeletal exam: Cranial nerves II-XII are grossly intact. No cerebellar signs are noted. No evidence of a gait disturbance. DTRs are 1+/4+ and equal throughout. Good uptoeing. Skin: Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1. Weight-gain.,2. Hypertension.,3. Lipometabolism disorder.,4. Rectal bleeding.,5. Left knee pain.,6. Question of sleep apnea.,7. Upper respiratory infection, improving.,8. Gynecological examination is unremarkable for her age.,PLAN:, We discussed at length, the issue of sleep apnea and its negative sequela. I have recommended that she be referred for a sleep study. She is certainly at risk for sleep apnea. She refuses this. I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better. I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable. I reviewed this with her. I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them. I will dictate Dr. XYZ a note. I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort. She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her. This however, has been some time ago. I suspect she has an element of irritable bowel syndrome. I have strongly encouraged weight reduction, both through diet and exercise. I would like to see her back in the office in six months. I did retake her blood pressure today and it was 130/70. She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK. I will her mail the results. I have strongly encouraged medication management if her lipids are elevated. I think she is amenable to this. Her DEXA scan is up to date having been done on 04/09/03. I do not recommend one this year.

A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.

General Medicine

Gen Med Progress Note - 5

she, her, is, has, does

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. She follows with Dr. XYZ on her hypertension, as well as myself. She continues to gain weight. Diabetes is therefore a major concern. In fact, her dad had diabetes and she has a brother who has diabetes. The patient also has several additional concerns she brings up today. One is that her left knee continues to bother her and it hurts. She cannot really isolate where the pain is, it just seems to hurt through her knee. She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999. There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially. She would like to have this x-rayed again today. She is certainly not interested in any surgery. She has noted that it particularly hurts to kneel. In addition, she complains of her stools being a baby-yellow. She has rectal bleeding off and on. It is bright red. She had a colonoscopy done in 1999. She does have a family history of colon cancer questionable in her mother, who is deceased. She complains of some diffuse abdominal pain off and on. She has given up fast foods and her pop and this has not seemed to help. She does admit however, that she is not eating right. Sometimes her stools are hard. Sometimes they are runny. The blood does not really seem to be related to necessarily a hard stool. It is always bright red and will sometimes drip into the toilet. Over the last couple of days, she had also been sneezing and has had an itchy throat. She tried some Claritin and this did not help. She has had some body aches. She is finally feeling better today with this. She also is questioning whether she has some sleep apnea. She will awaken suddenly in the middle of the night. She was told that she does snore. She does not smoke. As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy.,PREVENTATIVE HISTORY:, She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:, Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:, Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:, Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General: Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals: Her weight today is 246 pounds. In March of 2002 she weighed 231 pounds. In March 2001 she weighed 203 pounds. Her blood pressure is 160/78. Pulse is 84. Respiratory rate of 20. She is afebrile.,HEENT: Head is of normocephalic, atraumatic. PERLA. Conjunctivae clear. TMs are unremarkable and canals are patent. Nasal mucosa is slightly reddened. Nares are patent. Throat shows some clear posterior pharyngeal drainage. Throat is slightly reddened. Non-exudative. No oral lesions or dental caries noted.,Neck: Supple, No adenopathy. Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart: Regular rate and rhythm without murmurs, clicks or rubs. PMI is nondisplaced.,Lungs: Clear to A&P. No CVA tenderness.,Breast exam: Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge. Breasts were examined both lying and sitting.,Abdomen: Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses. Non tender.,Pelvic exam: BUS unremarkable. Speculum exam shows normal physiologic discharge. There are some atrophic vaginal changes. Cervix visualized, no gross abnormalities. Pap smear obtained. Bimanual is negative for any adnexal masses or tenderness. Rectal exam is negative for any adnexal masses or tenderness. No rectal masses. She does have some external hemorrhoids, none of which are inflamed at this time. No palpable rectal masses.,Neuromusculoskeletal exam: Cranial nerves II-XII are grossly intact. No cerebellar signs are noted. No evidence of a gait disturbance. DTRs are 1+/4+ and equal throughout. Good uptoeing. Skin: Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1. Weight-gain.,2. Hypertension.,3. Lipometabolism disorder.,4. Rectal bleeding.,5. Left knee pain.,6. Question of sleep apnea.,7. Upper respiratory infection, improving.,8. Gynecological examination is unremarkable for her age.,PLAN:, We discussed at length, the issue of sleep apnea and its negative sequela. I have recommended that she be referred for a sleep study. She is certainly at risk for sleep apnea. She refuses this. I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better. I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable. I reviewed this with her. I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them. I will dictate Dr. XYZ a note. I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort. She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her. This however, has been some time ago. I suspect she has an element of irritable bowel syndrome. I have strongly encouraged weight reduction, both through diet and exercise. I would like to see her back in the office in six months. I did retake her blood pressure today and it was 130/70. She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK. I will her mail the results. I have strongly encouraged medication management if her lipids are elevated. I think she is amenable to this. Her DEXA scan is up to date having been done on 04/09/03. I do not recommend one this year. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. [/DESCRIPTION] </s>