description stringlengths 14 491 | transcription stringlengths 13 15.2k | sample_name stringlengths 3 59 | medical_specialty stringclasses 13
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Right pleural effusion and suspected malignant mesothelioma. | PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:, General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural ef... | Mesothelioma - Pleural Biopsy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma, |
Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker. | PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS: ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a dual-chamber pacemaker.,2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Ve... | Pacemaker (Dual Chamber) - 1 | Cardiovascular / Pulmonary | null |
Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension. | REASON FOR EXAM:,1. Angina.,2. Coronary artery disease.,INTERPRETATION: ,This is a technically acceptable study.,DIMENSIONS: ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.,FINDINGS: , Left atrium was mildly to moderately dilated. No m... | Echocardiogram - 3 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly, |
Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. | REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y... | Rotator Cuff Tear | Neurology | neurology, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical, |
Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery. | PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The ... | Heart Catheterization, Ventriculography, & Angiography - 16 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography |
Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer. | PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED: ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration i... | Tongue Lesion Biopsy | Hematology - Oncology | hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy, |
Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope. | PREOPERATIVE DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1. Anterior cervical discectomy with decompression of spinal cord C7-T1.,2. Anterior cervical fusion, C7-T1.,3. Anterior cervical instrumentation, anterior C7-T1.,4. Insertion of... | Anterior Cervical Discectomy & Fusion - 6 | Neurosurgery | neurosurgery, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation, |
Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis. | PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of s... | Laryngoscopy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, paten... |
Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow. | 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: , ... | Closed Reduction Percutaneous Pinning | Orthopedic | orthopedic, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow, |
Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. | PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected... | Chest Closure | Cardiovascular / Pulmonary | cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation |
Bilateral myringotomies with insertion of Santa Barbara T-tube. | PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:,... | Myringotomy/Tube Insertion - 2 | ENT - Otolaryngology | ent - otolaryngology, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tub... |
Pain management sample progress note. | DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox inj... | Pain Management Progress Note | Orthopedic | orthopedic, progress note, management, muscle |
Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology. | REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be... | Air Under Diaphragm - Consult | Gastroenterology | null |
Twin pregnancy with threatened preterm labor. | GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm con... | Ultrasound OB - 4 | Radiology | null |
The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints. | Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal ... | Ortho Office Visit | Orthopedic | orthopedic, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accura... |
Pediatric Gastroenterology - Rectal Bleeding Consult. | HISTORY OF PRESENT ILLNESS:, This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was ha... | Rectal Bleeding - 1-year-old | Pediatrics - Neonatal | null |
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: , Le... | Lumbar Laminotomy & Discectomy | Neurosurgery | 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, |
Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative. | INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: ,Procedure and complications explained to the patient in detail. Informed consent was obtained. The patient was anesthetized in the throat with lidocaine spray. Subsequently, 3 mg of IV Versed was given for sedation. The pa... | Transesophageal Echocardiogram - 1 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves |
Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. | CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS: ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was... | Consult - Seizures - 2 | Neurology | null |
Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee. | PREOPERATIVE DIAGNOSIS:, Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1. Arthroscopy of the left knee.,2. Left arthroscopic medial meniscoplasty of medial femoral condyle.,3. Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: ,... | Arthroscopy, Meniscoplasty, & Chondroplasty | Orthopedic | orthopedic, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral |
Normal awake and drowsy (stage I sleep) EEG for patient's age. | DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. Du... | Electroencephalogram | Neurology | neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity |
MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old. | EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE: ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age. There are no... | MRI of Brain w/o Contrast. | Neurology | neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast, |
The patient comes for three-week postpartum checkup, complaining of allergies. | CHIEF COMPLAINT:, The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:, She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, n... | Three-Week Postpartum Checkup | Obstetrics / Gynecology | obstetrics / gynecology, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup, |
Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. | PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: ... | Cholecystectomy Laparoscopic | Gastroenterology | gastroenterology, gallstone, gallbladder, pancreatitis, anterior abdominal wall, video laparoscope, laparoscopic cholecystectomy, omental adhesions, veress needle, cystic duct, injectable, adhesions, cholecystectomy, laparoscopic, abdomen |
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Retrieves records related to asthma from various text fields, providing a basic overview of entries mentioning asthma.